Biznet Networks - Service Change Form

Note: Please provide detailed information so we can provision the service faster. Please scan & email the Order Form, or fax to +62-21-5700580.

Customer Information

Customer ID:
Previous Company Name/Customer Name: / New Company Name/Customer Name:
Previous NPWP: / New NPWP:
Previous Address/Billing Address: / New Address/Billing Address:
Contact Person: / Contact Person:
Contact Title: / Contact Title:
Phone: / Phone:
Fax: / Fax:
Mobile: / Mobile:
Email: / Email:
Notes: / Notes:

Service Information

Previous Service Type: / New Service Type:
Previous Monthly Fee: / New Monthly Fee:
Effective Date: / Notes:

Installation Information

Previous Installation Address - Node A: / New Installation Address - Node A:
Previous Installation Address - Node B: / New Installation Address – Node B:

*for relocation

Payment Information

Previous Payment Type: / New Payment Type:

For payment with credit card, please fill the information

Credit Card Type: Master Card/Visa / Credit Card No:
Credit Card Name: / Credit Card Exp Date:

Authorization

This service change form will only be valid if terms and conditions is attached.
Note:
  • We hereby confirm that the information above is true and agree to be bound by Biznet’s Terms and Conditions which written on the proposal of Dedicated Internet and we are the authorized to signed the Order Form.
  • Biznet has the right to refuse this application without any explanation
  • Biznet’s Terms and Conditions may change at any time without prior notice
  • For credit card payment, we hereby authorize Biznet to charge the credit card for service type we chose.
/ Signature & Company StampPrint Name:
Date:

Please attach the following copies

[ ] Tax ID/NPWP for corporate customer, KTP/Passport/ID Card for personal customer

[ ] Credit Card (Front & Back) for payment with credit card only

PT Supra Primatama Nusantara - Service Change Form - Confidential Information 9/20/2018