Full Name |
|
Gender
|
|
Place & Date of Birth |
,
|
ID Card Type |
|
ID Card Number |
|
Address on ID Card |
|
Correspondence Address |
|
Post Code |
|
Residence Phone Number |
|
Cellular Phone Number (CDMA/GSM) |
|
Office Phone Number |
|
Fax. Number |
|
For
ADSL Only |
ADSL Phone Number |
|
|
FOR
COMPANY MEMBERSHIP, PLEASE ALSO COMPLETE THE FOLLOWING |
Company Name |
|
NPWP |
|
Company Address |
|
Time
Based
Personal Internet Services
Corporatel Internet Services
|
* Please
call our marketing department at (031) 548-0500 for availability
and prices
|
Username Preferences 1* |
|
Username Preferences 2 |
|
Username Preferences 3 |
|
Email 1 |
|
Email 2 |
|
*Your username
will be your primary email address |
|