Hari/Day :

Tanggal/Date :
FORMULIR PERUBAHAN DATA MERCHANT/CHANGES MERCHANT DATA FORM
DATA MERCHANT LAMA/ DATA MERCHANT BARU/
OLD MERCHANT DATA NEW MERCHANT DATA
Nama Merchant/Merchant Name :

Alamat/Address :

Kota/City :

Kode Pos/Zip Code :

Kontak Person/Contact Person* : Kontak Person/Contact Person* :

Telp//Mobilephone* : Telp/Mobilephone* :

Alamat Email/Email Address* : Alamat Email/Email Address* :

No. Rekening/Account Number* : No. Rekening/Account Number* :

Nama Pemilik Rekening/Account Holder Name* : Nama Pemilik Rekening/Account Holder Name* :

Nama Bank/Bank Name* : Nama Bank/Bank Name* :

User Id Mobile Apps/Web Apps* : User Id Mobile Apps/Web Apps* :

Alasan/Reason :

Pemohon Merchant Lama Pemohon Merchant Baru,

Old Merchant Applicant, New Merchant Applicant,

Meterai/Stamp Rp.6.000,-

( ) ( )

*Setiap permohonan perubahan Kontak Person, Telp/Handphone, Email, Nomor Rekening, Nama Pemilik Rekening, Nama Bank dan User
ID Mobile Apps/Web Apps wajib melampirkan meterai Rp.6.000,- (enam ribu rupiah) dan ditandatangani oleh Pemohon Merchant Lama
dan Pemohon Merchant Baru sebelum dikirim ke PT. Cashlez Worldwide Indonesia. Every application for change of Contact
Person,Phone/Mobile,Email,Account Number,Account Holder Name,Bank Name and Mobile Apps/Web Apps User ID mandatory attach
IDR 6.000 stamp (six thousand rupiah) and be signed by the Old Merchant Applicant and New Merchant Applicant before send to PT.
Cashlez Worldwide Indonesia.
Note : Formulir perubahan data merchant yang telah ditandatangani ini merujuk sebagai Surat Kuasa dibuat dengan sebenar-benarnya
sesuai permohonan dari merchant yang bersangkutan diberikan oleh pihak Pemohon Merchant Lama dan Pemohon Merchant Baru
kepada PT. Cashlez Worldwide Indonesia sebagai Merchant Aggregator untuk dilaksanakan perubahan pada sistem dan PT. Cashlez
Worldwide Indonesia dibebaskan dari segala tanggung jawab atas tuntutan perkara perubahan data merchant ini dikemudian hari.The
Signed merchant data change form refers to the power of attorney made truthfully according to the request of the concerned merchant
given by the old merchant applicant and new merchant applicant to the PT. Cashlez Worldwide Indonesia as a merchant aggregator to
implement changes into the system and PT. Cashlez Worldwide Indonesia is freed from all responsibility for demands of this merchant
data change case in the future.