Form Change Address 1

Contact us :

Changing Customer’s Data

Manggala Wanabakti IV, 6th Floor Jl. Gatot Subroto, Senayan Jakarta 10270 Tel. (021) 5799-4588 Fax. (021) 574-2481

internet @ your. fingertips

EXISTING DATA Date

:

Customer ID

:

Login Name

:

_______________________________________________

Full Name

:

_______________________________________________ (as stated in KTP/KIMS/Passport)

KTP/Passport

:

_______________________________________________

Company

:

________________________________________________ (for corporate service only)

Service Type

:

________________________________________________

Telephon & Fax

: __________________________________________________

______ /______ /___________ -

-

Change Ownership Account

Herewith to transfer all of the right and obligation as a CBN’s customer to

NEW DATA Name

: ___________________________________________________________ ( according to KTP/ KIMS/Paspport )

Company

:

_____________________________ ( for corporate service )

Phone Number

: ___________________________________________________________ Signature

Date of Birth

:

___________________________

KTP/Passport

:

_________________________________________________

*Stamp Duty

Reason

:

_________________________________________________

( _____________________ )

Herewith to accept all of the right and obligation transferred as a CBN’s customer

Name

* For changing ownership account customer have to sign on a stamp duty

Change Billing Address Home Address

Herewith to inform the changes of data Office _________________________________________

: __________________________________________________________________________________________ __________________________________________________________________________________________

City / Zip Code

: ____________________________ / ________________

Telephone/Fax

: ____________________________ / ________________

Create New C Card

Handphone : ____________________________

Signature

For create new C Card will be charge Rp 20.000/card + PPN 10% I shall be responsible for any information given herein

All rules and regulations stated by CBN may change at anytime. These rules applies from the time when CBN issued the statement. Please reconfirm to Customer Care after fax this form.

MKT – PDP2005 - 2

(_________________________) Name

Please attach your copy of Identification ( KTP/KIMS/Passport ) MKT/PDP2/2005-01