FORMULIR SEMENTARA BERLANGGANAN INDOVISION
Nama Pelanggan : __________________________________________
No. Identitas/KTP : ________________________________________
Alamat Pemasangan : ______________________________________
______________________________________________________
Tempat &Tgl Lahir: ________________________________________
Tlp Rumah : _______________________________________________
Tlp Kantor : _______________________________________________
HP : _____________________________________________________
No. Fax : _______________________________________________
Jenis Kelamin : ____________________________________________
Status Pernikahan : ________________________________________
Agama : ________________________________________________
Pekerjaan : ________________________________________________
Golongan Darah : __________________________________________
Emergency Call (EC) : _______________________________________
No.tlp/ HP EC : _____________________________________________
Hubungan dengan EC :______________________________________
Plihan Paket : ______________________________________________
Bila sudah diisi tinggal kirim balik ke email : ferra_avrianty@yahoo.com
