Registrations Form

REGISTRATIONS FORM (One Registrations Form Valid only for one Customer) Product Information/ Informasi Produk Product Name Nama Produk

:

Card Membership EC

Rp 200.000

Card Membership Reguler Frinchise Hak Frinchise

:

Product Serial Number* No. Seri Produk*

Rp 150.000

1 Hak Usaha

Rp 200.000

3 Hak Usaha

Rp 500.000

7 Hak Usaha

Rp 1.100.000

:

*Cek No. Serial Kartu Anda di www.duta4future.com untuk memastikan kartu Anda Valid. Agent Information/ Informasi Card Agency Date of Purchase 6550149921 Tanggal Pembelian

:

Account Number.

: BCA

No. Rekening

Agent Name 3275082812700009 Nama Agen

:

Edi Supriyatno

ID Card No.

:

Agent Adress Alamat Agent Pembelian

: Jl. Vanda No 15, Perum. Jatibening I Postal Code : 17412 Pondok Gede, Bekasi- Indonesia Kode Pos

Agent Phone Number 08129462845 Nomor Telephone

:

No. KTP/SIM/Paspor

021-8468611

Mobile Phone

:

Customer Information/ Informasi Pelanggan Full Name : Nama Lengkap

:

Account Number No. Rekening

ID Card No No. KTP/SIM/Paspor

:

Mobile Phone : Handphone

Home Address Alamat Rumah

:

Nama Gadis Ibu

:

Home Phone Telephone Rumah

:

Ahli waris

:

Postal Code Kode Pos

:

....................................., .............,.................. City , dd-mm-yy

E-mail

:

Customer,

(

Owner,

)

(

) Signature & Name Signature & Name

Mohon Formulir Registration dan Bukti Transfer kirim ke Fax (021) 3512065 atau ke email: [email protected]