Biznet Networks - Termination Form

Note: Please provide detailed information so we can provision the service faster. Please scan & email the Termination
Form, or fax to +62-21-5700580.

Customer Information
Company Name/Customer Name:

Customer ID:

Email:

Service Information
Service Type:

Reason For Termination:

Payment Information
I would like to pay my bill amounting __________ with :
[ ] Cash
[ ] Bank Transfer to: BCA / Bank Permata / Bank of Tokyo - Mitsubishi
[ ] Cheque
[ ] Credit Card Master Card/Visa
Credit Card No: _____________________
Expired Date: _____________________

Authorization
With this letter, I would like to ask Biznet to terminate service package that I have this moment as of ___________
(date)

Signature & Company Stamp Print Name:

Date:

Internal Use
Account Manager Billing / Customer Care Hosting Engineer

Date Date Date

Signature
PT Supra Primatama Nusantara - Termination Form - Confidential Information 8/26/2018