You are on page 1of 1

Contact us :

Changing Customer’s Data Manggala Wanabakti IV, 6th Floor


Jl. Gatot Subroto, Senayan
Jakarta 10270
internet @ your. fingertips Tel. (021) 5799-4588
Fax. (021) 574-2481

EXISTING DATA
Date : ______ /______ /___________

Customer ID : - -

Login Name : _______________________________________________

Full Name : _______________________________________________ (as stated in KTP/KIMS/Passport)

KTP/Passport : _______________________________________________

Company : ________________________________________________ (for corporate service only)

Service Type : ________________________________________________

Telephon & Fax : __________________________________________________

Change Ownership Account Herewith to transfer all of the right and obligation as a CBN’s customer to

NEW DATA
Name : ___________________________________________________________
( according to KTP/ KIMS/Paspport )

Company : _____________________________
( for corporate service )
Phone Number : ___________________________________________________________
Signature
Date of Birth : ___________________________

KTP/Passport : _________________________________________________ *Stamp Duty

Reason : _________________________________________________ ( _____________________ )

Herewith to accept all of the right and obligation transferred as a CBN’s customer Name
* For changing ownership account customer have to sign on a stamp duty

Change Billing Address Herewith to inform the changes of data

Home Office _________________________________________

Address : __________________________________________________________________________________________

__________________________________________________________________________________________

City / Zip Code : ____________________________ / ________________

Telephone/Fax : ____________________________ / ________________ Handphone : ____________________________

Create New C Card Signature


For create new C Card will be charge Rp 20.000/card + PPN 10%

I shall be responsible for any information given herein (_________________________)


Name

All rules and regulations stated by CBN may change at anytime.


These rules applies from the time when CBN issued the statement. Please attach your copy of Identification
( KTP/KIMS/Passport )
Please reconfirm to Customer Care after fax this form. MKT/PDP2/2005-01

MKT – PDP2005 - 2