Formulir DoD - Dial on Demand

  Bandwith :
32 kbps
64 kbps
128 kbps
  Type of Account :
50 hours
100 hours
 
  Term :
Monthly
6 Months
1 Year
  Full Name :
..................................................................................................
  Address :
..................................................................................................
  Contact Phone No :
..................................................................................................
  ID Card :
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  Login Name :
  Password :
  Email Address :
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  Operating System :
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Method of Payment
 
Cash
DP
: Rp. ................................................................................................
 
Transfer
To : PT INTERNET MADJU ABAD MILENINDO
    Account no : ......................................................................................................
    Bank : ......................................................................................................
         
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Customer's Sign
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Official

 


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MALANG
Jl.Retawu no 8
Malang-65112
telp.(0341)56 2000
fax.(0341)583 933
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Kuta-Bali 80361
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