Formulir Berlangganan

Subscription Form
Tanggal Daftar : / / 20 ...... Kode Promo ............................................. No ID .................................................
Register Date Promo Code ID Number

Nama Lengkap sesuai KTP : ........................................................................................................................................... L P

Full name as stated in ID Card M F

Alamat Instalasi : ..............................................................................................................................................................................................................

Installation Address

Kota/City : ................................... Provinsi/Province : ................................... Kode Pos/Zip code : ................................

Jenis Tempat Tinggal Rumah Tinggal/Recidential Home Apartement/Apartment Lainnya/Others ......................................

type of recidential

Nomor Telepon/Email* Rumah/Home Ponsel/Mobile Phone Email (*Pengiriman Tagihan/invoice) :

Phone Number

............................................... ............................................... ...............................................

Nomor KTP : ..............................................................................................................................................................................................................

ID Card Number

Tempat/Tgl Lahir : ..............................................................................................................................................................................................................

Place & date of birth

Alamat sesuai KTP : ..............................................................................................................................................................................................................

Address as stated ini ID card
Kota/City : ......................................... Provinsi/Province : ................................ Kode Pos/Zip code : ................................

Pekerjaan Wiraswasta Karyawan Ibu Rumah Tangga Lainnya : ..............................................

Job Entrepeneur Employee House Wife Others

Mohon isi sesuai dengan paket yang anda pilih / Please ll in accordance with the package you choose:
Pilihan Paket Internet Nama Paket : ................................................................................................... Harga Rp. ......................................................
Internet Package Option Package Name : ................................................................................................... Price
Pilihan Add on : ................................................................................................... Harga Rp. ......................................................
Add On Option Price

Cara Pembayaran Total Biaya Berlangganan Per Bulan / Total Subscription Fee Per Month:
Pembayaran dilakukan paling lambat tanggal 10 setiap bulannya / Total Biaya Bulanan :
Payments are made at least on the 10th every months Total Monthly Payment

Pembayaran dapat dilakukan melalui ATM/setor tunai di Bank BCA Biaya Paket Internet Rp. .....................................
Internet Package Fee
dan BCA Klik pay / Payment can be made via ATM / cash deposit (untuk paket internet saja / Internet only)
at BCA Bank and BCA Klik pay Biaya Add on Rp. .....................................
Ke Rekening Bank BCA / BCA bank account Add On Fee
Nomor / Number : 816 5 409 899 Sewa Smart Box 1/2/3 Rp. .....................................
Smart Box 1/2/3 Rent
A/n : PT. Media Sarana Data
TOTAL Rp. .....................................
Catatan / Additional Note : Total Biaya Bulanan :
Total Monthly Payment
Biaya Instalasi Rp. .....................................
Installation Fee
TOTAL Rp. .....................................
Total Pembayaran Pertama :
First Payment
Total Biaya Bulanan Rp. .....................................
ITotal Monthly Payment
Total Biaya 1 (Satu) Kali Di Muka Rp. .....................................
Total one time payment
Rp. .....................................

PPN 10% Rp. .....................................

VAT 10%
GRAND TOTAL Rp. .....................................
Dilarang keras memberikan uang tunai kepada tim di lapangan dengan alasan apapun / Don't give any tips to the eld team by any reasons
Kami dari pihak Fiberstream tidak bertanggung jawab atas kerugian yang terjadi dari penipuan yang dialami / We don't have any responsibilities for nancial
loss that caused by any deceptions

Syarat & Ketentuan / Terms & Conditions: Menyetujui penalti Rp 1.000.000,-

1 Masa berlangganan minimal 12 bulan jika berhenti berlangganan sebelum 12 bulan
12 months minimum subscription Agree a penalty of Rp 1,000,000 if you unsubscribe less than 12 months
2 Keterlambatan pembayaran berlangganan bulanan dikenakan denda Rp. 50.000
Delayed payment of monthly subscription will get ned Rp 50000
3 Seluruh Biaya belum termasuk PPN 10%
All price exclude VAT 10% Nama dan tanda tangan
Name & Sign

PT Media Sarana Data Pelanggan/Customer

materai

(....................................................................) (....................................................................)