PT.

SINERGI TRIDAYA MEDICAL

Green Office Park 6 (MyRepublic Plaza)
3rd floor Wing B, Zone 7C Jl. Grand Boulevard, BSD City

FORM REQUEST NEW CUSTOMER

No : (Nomor akan diisi oleh HO - Dian)

Requester :

Tanggal :

Isi dengan Lengkap dan Jelas

Ship to Party * :: *(Isi namanya saja tanpa Title)

Title Ship to Party Bend Prof. dr RSPAD RSUPN APT

DIR Prof. Dr. dr. RSU RSAB
dr Prof. Dr. drg RSUD RSAL
PT Prof. drg RSUP RSAU
CV RS SMF RSPAU
Dr. dr RSGM UNV RST
drg RSI YAY RSKB

Billing to Party (sesuai NPWP) * :

Title Billing to Party Bend Prof. dr RSPAD RSUPN APT

DIR Prof. Dr. dr. RSU RSAB
dr Prof. Dr. drg RSUD RSAL
PT Prof. drg RSUP RSAU
CV RS SMF RSPAU
Dr. dr RSGM UNV RST
drg RSI YAY RSKB

Address :

City (Kabupaten) :

Province :
Phone : +62

Fax :

No NPWP :

Area : Medan Palembang Kalimantan and Manado

National East Java Central Java
Medan
West Java Makassar

PIC Finance Name :

PIC Finance Email :
PIC Finance Phone : +62
PIC Logistic Name :
PIC Logistic Email :
PIC Logistic Phone : +62

Category : Doctor / Physician Government Hospital Customer Code :

Coorporate Private Hospital

Approved by, Created by,

Meyske Dian Tika M.

Date : Date :