No.

Formulir
(No Formulir) W35374
FORMULIR PEMBELIAN AWAL UNIT PENYERTAAN INDIVIDU
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Kepada/To : PT. Panin Asset Management Tel : +62 21 5150595 / +62 21 5150605
Indonesia Stock Exchange Tower 1, Lantai 3, Suite 306, Fax : +62 21 5155627
Jl. Jendral Sudirman Kav. 52-53, Jakarta 12190, Indonesia Email : cs@panin-am.co
.id
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Saya/ Kami ingin melakukan investasi dalam Reksa Dana dibawah ini/ .............
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PANIN DANA MAKSIMA
REKSA DANA SAHAM
PANIN DANA PRIMA
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REKSA DANA CAMPURAN
PANIN DANA UNGGULAN
PANIN DANA BERSAMA PLUS
PANIN DANA US DOLLAR
PANIN DANA PRIORITAS
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REKSA DANA PENDAPATAN TETAP
PANIN DANA UTAMA PLUS 2
PANIN GEBYAR INDONESIA II
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REKSA DANA PASAR UANG
PANIN DANA LIKUID
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REKSA DANA SYARIAH
PANIN DANA SYARIAH SAHAM
PANIN DANA SYARIAH BERIMBANG
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INFORMASI PEMESAN / ............................................^
Wajib diisi seluruhnya / ..................................................
Phone Telp Celular/
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Kelurahan Kecamatan
Kota / .......
Kode Pos / ....................G
Alamat (sesuai ID) / ...................
RT RW
Kelurahan
Email
Kecamatan
Kota / .......
Kode Pos / ....................G
Alamat Korespondensi / .........................................
RT RW
Kewarganegaraan / ...................
WNI WNA
Nama Tengah / ....................G
Nama Belakang / ................G
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Gelar Sebelum Nama/ ................................G
Gelar Sesudah Nama/ ............................G
Nama Depan (sesuai ID) / .......................................................
KTP / ..............
NPWP /
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Masa Berlaku /
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Day Month Year
Day Month Year
Tempat Lahir / ..........................S
Tanggal Lahir / Date of Birth
Day Month Year
Laki-laki / ......G
Jenis Kelamin / Gender
Perempuan / ..........G
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(text) diaz.bdc@gmail.com
Nilai Pemesanan/ ................
Reksa Dana/ ....................E
Reksa Dana/ ....................E
Reksa Dana/ ....................E
Rp
Nilai Pemesanan/ ................
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Nilai Pemesanan/ ................
Rp
PEMESANAN / APPLICATION
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resiko-resiko utama dari Reksa Dana.
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Diisi oleh Manajer Investasi/ Agen/ ............................................
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Tempat/ Place Tanggal/ Date Tanggal diterima :
Jam:
,
(Sticky Note comment 18/09/2012 14:29:13
distributed)
Persentase :
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Tanda Tangan dan Nama Jelas Tanda Tangan dan Nama Jelas
Signature and Name Signature and Name

No. Formulir
(No Formulir) W35374
TAMBAHAN DATA/ INFORMASI NASABAH PERORANGAN
ADDITIONAL DATA/ INFORMATION OF INDIVIDUAL CUSTOMER
Phone Fax
Alamat Perusahaan / Business Address
URAIAN BIDANG USAHA ATAU PEKERJAAN / BUSINESS OR JOB DESCRIPTION
Nama Perusahaan / Business Name
Bidang Usaha / Business Nature
Jabatan / Job Title
Profesi / ..................
Pelajar / Mahasiswa / Student
Ibu Rumah Tangga / Housewife
Pengusaha / Wiraswasta / Entrepreneur
PNS / BUMN / Civil Servant
TNI / Polisi / TNI / Police
Pensiunan / ..................
Guru / Dosen / Teacher
Pegawai Swasta / Private Employee
Lainnya / Others
Email
Nama Perusahaan / Business Name
INFORMASI KELUARGA / FAMILY INFORMATION
Nama Suami / Istri / Orang Tua / Spouse / Parent Name
Bidang Usaha / Business Nature
Status Perkawinan / Marital Status Lajang / Single Menikah / Married Duda / Jand
a / Widower
Profesi / ..................
Pelajar/Mahasiswa / Student
Ibu Rumah Tangga / Housewife
Pengusaha/Wiraswasta / Entrepreneur
PNS/BUMN / Civil Servant
TNI / Polisi / TNI / Police
Pensiunan / ..................
Guru/Dosen / Teacher
Pegawai Swasta/ Private Employee
Lainnya / Others
INFORMASI NASABAH / CUSTOMER INFORMATIONS
Nama / Name
Alamat sesuai ID / ID Address
Lampiran / ..................Fotokopi KTP / Photo copy ID / Passport Fotokopi NP
WP / Photo copy Tax ID Number
Agama / Religion
Islam Protestan Katolik Hindu Budha Kong Hu Cu Lainnya
Latar Belakang Pendidikan / ..........................................
SD / Elementary School
SMP / Junior High School
SMA/ SMK / Senior High School
Diploma / Academy
Sarjana S1 / University Degree
Pasca Sarjana S2 / Master Degree
Doktor S3 / Doctoral Degree
Lainnya / Others
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(SD / Elementary School) Unchecked
(Diploma / Academy) Unchecked
(Doktor S3 / Doctoral Degree) Unchecked
(SMP / Junior High School) Unchecked
(Sarjana S1 / University Degree) Unchecked
(Lainnya / Others) Unchecked
(SMA/ SMK / Senior High School) Unchecked
(Pasca Sarjana S2 / Master Degree) Unchecked
(Fotokopi KTP / Photo copy ID / Passport) Unchecked
(Fotokopi NPWP / Photo copy Tax ID Number) Unchecked
(Pelajar / Mahasiswa / Student) Unchecked
(Guru / Dosen / Teacher) Unchecked
(Ibu Rumah Tangga / Housewife) Unchecked
(Pegawai Swasta / Private Employee) Unchecked
(PNS / BUMN / Civil Servant) Unchecked
(TNI / Polisi / TNI / Police) Unchecked
(Pensiunan / ZGO.GwGYl) Unchecked
(Pengusaha / Wiraswasta / Entrepreneur) Unchecked
(Lainnya / Others) Unchecked
(Lajang / Single) Unchecked
(Menikah / Married) Unchecked
(Duda / Janda / Widower) Unchecked
(Pelajar/Mahasiswa / Student) Unchecked
(PNS/BUMN / Civil Servant) Unchecked
(Guru/Dosen / Teacher) Unchecked
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(TNI / Polisi / TNI / Police) Unchecked
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(Pengusaha/Wiraswasta / Entrepreneur) Unchecked
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Phone Fax
Alamat Perusahaan / Business Address
Jabatan / Job Title
Email
Ahli Waris/
Heir
Hubungan/
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PENGHASILAN BERSIH TAHUNAN / ANNUAL NET INCOME
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MAKSUD & TUJUAN / OBJECTIVES
Keuntungan / ................................Y
Investasi Jangka Panjang / Long Term Investment
Spekulasi / ..................Y
Lainnya/ Others
Mendapat Penghasilan / Earn a living
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SUMBER UTAMA DANA / MAIN SOURCE OF FUNDS
Hasil Usaha / Business Revenue
Dana Pensiun / Pension Fund
Bunga Simpanan / Interest Savings
Lainnya/ Others
Hasil Investasi / Return on Investment
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INFORMASI REKENING BANK 1 / BANK ACCOUNT INFORMATION 1

Nomor Rekening /
Acc Number
Mata Uang /
Account Currency
Nama Pemilik Rekening / Acc Name
Bank
Cabang /
Branch
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(text)
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INFORMASI REKENING BANK 2 / BANK ACCOUNT INFORMATION 2
Nomor Rekening /
Acc Number
Mata Uang /
Account Currency
Nama Pemilik Rekening / Acc Name
Bank
Cabang /
Branch
(text)
(text)
(text)
(text)
(text)
INFORMASI REKENING BANK 3 / BANK ACCOUNT INFORMATION 3
Nomor Rekening /
Acc Number
Mata Uang /
Account Currency
Nama Pemilik Rekening / Acc Name
Bank
Cabang /
Branch
(text)
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PERNYATAAN / STATEMENT
Saya / Kami menyatakan bahwa I / We hereby duly stated that :
1. Semua data/informasi yang tertulis dalam formulir ini adalah benar. / .......
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Nama / Name:
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(AUA.lA. . ..)
(Nama / Name)
(Nama / Name)

FORMULIR PROFIL PEMODAL REKSA DANA UNTUK INDIVIDU

(No Formulir) W35374
Kepada/To : PT. Panin Asset Management Tel : +62 21 5150595 / +62 21 5150605
Indonesia Stock Exchange Tower 1, Lantai 3, Suite 306, Fax : +62 21 5150601/ +62
21 5155628
Jl. Jendral Sudirman Kav. 52-53, Jakarta 12190, Indonesia Email : assetmgt@panin
-am.co.id
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Kami mohon Bapak/ Ibu dapat memilih jawaban yang sesuai di bawah ini dengan memb
erikan tanda (X)
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B. Kurang E. Sangat Baik
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UNTUK MARKETING
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KTP
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NPWP
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(Tempat)
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Tempat Tanggal Waktu
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UNTUK NASABAH

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KTP
NPWP
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Tempat Tanggal Waktu
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