| 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 |
|
|
