PT.

MORA TELEMATIKA INDONESIA No

Grha 9, 6th floor, Jalan Panataran No.9 Proklamasi, Jakarta Pusat 10320, Indonesia Ref
Ph: +62-21-3199 8600 Fax: +62-21-314 2882 www.moratelindo.co.id Date

INTERNET REGISTRATION FORM

SERVICE Oxygen Soho SuperNET Mix (Blended Internet: IX and IIX)
Please tick one Oxygen Dedicated

■ Company Information
Subscriber ID (filled by Moratelindo) Existing Subscriber ID (filled by Moratelindo)
Name of Company
Correspondence Address
Phone Ext Mobile Fax
Name of Authorized Officer Designation
ID Number/Passport
Tax Registration Number
Name of Director

■ Billing Information
Name of Finance Officer
Billing Address
Phone Ext Mobile Fax

Email

■ Requirement Information
Link Destination Payment in X IDR USD

No Description Capacity-Type* Installation Cost Total Monthly Total

* Type of Service : Mbps Total Amount

VAT 10%
Up Grade Link From to Type of connection Grand Total
Date of service required Gbic
Contact Period (month) Ethernet

■ Site and PIC Information

No Name of Site Address PIC Mobile Email
1

We hereby confirm that the foregoing information herein given to be true and correct, and will follow the Terms and Conditions Internet Subscription.
We agree to be bound by the Terms and Conditions Internet Subscription as attached with this form.

Subscriber Approval By
PT. Mora Telematika Indonesia
Materai 6000 (Moratelindo)

. . . .
Date of Received : . Date of Received : .