TERMINATION FORM

CUSTOMER DATA

Full Name :
Occupation :
Company Name :
Address :

City : Postal Code :

Office Phone No. : Facsimile :
Home Phone No. : Handphone :

PACKAGE

LOCAL ACCESS
Ready Port Fiber Optic W'less 2.4 Ghz W'less 5.7 Ghz Leased Line Others :
BACKBONE CIR
VSAT Fiber Optic 1:1 1:2 1:4
BANDWIDTH NEEDS
64 kbps 128 kbps 256 kbps 512 kbps 1024 kbps Others :

Reason of Termination :

Termination Date :

UNDERTAKING

I hereby confirm that I will terminate my account and paid my outstanding balance.
Termination will be effective at 00.00 AM on Termination Date.

Company's Stamp
Signature :

Name :

Job Tittle :

Date :

FOR INTERNAL USE

Request by, Approved by, Terminating by, IP Address :

Route :

Interface :
Account Manager Director Finance NOC
This application is legal agreement between Applicant and Interlink after completed and signed by Applicant.