Formulir Dial Up

  Type of Account :
Bach
Choppin
Vivaldi
Beethoven
Mozart
 
  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 : ............................................................................@dps.globalxtreme.net
  
  Operating System :
Win 3.x
Win 95/98
Win 2000/NT
Mac
 
Other ...
  
Method of Payment
 
Cash
 
DP
: Rp. ................................................................................................
 
Transfer
  To : PT INTERNET MADJU ABAD MILENINDO
      Bank : BCA Kuta  
        : Acc. No. 1460-991-991  
      Bank : BII Cabang Udayana  
        : Acc. No. 2-019-902080  
  I agree to be bound by GlobalXtreme membership terms and conditions
 

Customer's Sign
Denpasar, ................................

 

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

 Dealer's Stamp

Official

 


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



 
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