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RECEIPT

Number : #1705696538805688999
Date : 19 Jul 2021, 14:16 (Monday)

PAYMENT DETAILS
P.O. NUMBER: 709467882 METHOD: PayLater STATUS: Paid

CUSTOMER DETAILS COMPANY DETAILS


Name : Marthaleina Name : Trinusa Travelindo
Email : novyana.e@gmail.com NPWP : 31.616.320.3-031.000
Contact Number : +628118461116 Address : Traveloka Campus [d/h Green Office Park] South Tower
2nd Floor Zone 10, Jl. Grand Boulevard BSD Green Office
Park, Sampora, Cisauk, Kab Tangerang, Banten 16345

MISS Novyana Evalinda

PRODUCT DETAILS
COVID-19 Antigen Swab (Rapid Antigen) Test Other
Product Name: MRCCC Siloam Hospitals Semanggi
Activity: COVID-19 Antigen Swab (Rapid Antigen) Test
Date: Mon, 19 Jul 2021
Other: 4

PURCHASE DETAILS

No Type of Item Item Description Qty Price per unit Rp Total Rp

1 Xperience Voucher COVID-19 Antigen Swab (Rapid Antigen) Test Other 4 197.600 790.400

2 COVID-19 COVID-19 Insurance by Asuransi Takaful Umum 1 16.500 16.500


Insurance

TOTAL 806.900

SERVICE FEE * 7.262

PAYMENT AMOUNT 814.162

*Includes 10% PPN

For any questions, visit Traveloka Help Center: www.traveloka.com/help

Terms and Conditions apply. Please refer to http://www.traveloka.com/termsandconditions

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