STK/DSTK REPLACEMENT REQUEST FORM

Doc No. :
Date : 26-04-2019

Request Type : v Replace STK/DSTK (to replace inactive/damaged/(lost)/stolen STK/DSTK)

Distributor Name : PT. BANGUN HARTA MANDIRI

Distributor STK MSISDN : -
Distributor Contact Name : ZULKIFLI N
Distributor Contact Phone : 0896 6666 6603

Retailer ID : 00049031
Retailer FL ID :
Saldo Terakhir :
Retailer Name : Kania
Retailer STK MSISDN : 89621451679
Retailer Contact Name : Nofrizon
Retailer Contact Phone : 89621451679
Retailer Address : Jln. Imam bonjol
(including Kecamatan)
……………………...………………………………………..

Remarks / Reason for Request

Old ICCID :

New ICCID : 896089 9000 6706 004430

Saldo : -

DUIT 3 :

KOIN 3 :

Requested By, Received By, Received By, Performed By,

(Zulkifli N ) ( ) ( ) ( )
Distributor TM Area H3I Business Executive H3I Head Of Branch 3Store Agent
Date : ……………… Date : …………… Date : ……....……… Date : ………....……