Formulir Dial Up

  Type of Account :
Entry
Classic
Executive
Platinum
 
  Term :
Monthly
6 Months
1 Year
 
  Full Name :
............................................... Date of Birth :..............................		  
  Address :
............................................... Postal Code :...............................		  
  Contact Phone No :
Home :.................................... Office :........................................		  
  ID # /KTP /SIM /Passport :
..................................................................................................		  
  Login Name :  
  Password :  
  Email Address :
..............................................................@....... .globalxtreme.net
  
  Operating System :
Win 3.x
Win 95/98
Win 2000/NT
Mac
 
Other ...
  
Method of Payment
 
Cash
 
DP
: Rp. ......................................................................................
 
Transfer
  Bank : BII Cab. Malang
        : a/n PT INTERNET MADJU ABAD MILENINDO  
        : Acc. No. 2-052-11167-7  
      Bank : BCA Cab. Malang  
          a/n Herry W Dotulong  
        : Acc. No. 011-030 6989  
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Customer's Sign
........................, ................................

 

( ............................................ )

 Dealer's Stamp

Official

 


( ............................................ )



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