Service Change Form

Name * Mr. YOGI RACHMAD DHARMAWAN

Salutation Full Name

Email * yogy.rd24@gmail.com

Mobile * +62 82264640303

E.g: +62 8125578xxxx

Mobile 2 +62 85850305676

E.g: +62 8125578xxxx

Customer ID * 1100000228724
E.g: CA2007XXXX/1100000XXXXXX

SIA ID * 3100000257597
E.g: 3100000XXXXXX/SI2002XXXX-XXXX

Service Change Type * Data Update

Service Change

Relocation

Biznet Service * Biznet Home

Biznet Metronet

Biznet Dedicated Internet

Biznet Educationnet / Biznet Healthnet

Biznet DataComm

Biznet Internet Exchange

Biznet Hospitality

Biznet BGP

Billing Account Number * 1100000228724

New Customer Information

Same W ith Previous Customer Information

Please attach new Tax ID/NPWP for corporate customer, KTP/Passport/ID Card for personal customer
 Service Change Form

New Billing Information

Same W ith Previous Billing Information

Billing Address * PERUMAHAN BUKIT CITRA DARMO

Street Address

BLOK CD C-15
Building Name

Surabaya
City

60198
Postal Code

Additional Billing Address * Benowo

District/Kecamatan

Sememi
Subdistrict/Kelurahan

Jawa Timur
State/Provinsi

Indonesia
Country

Contact Person * Mr. YOGY RACHMAD DHARMAWAN

Title Full Name

Phone * +62 82264640303

E.g: +62 21998XXX

Mobile * +62 85850305676

E.g: +62 8125578xxxx

Mobile 2

E.g: +62 8125578xxxx

Email * yogy.rd24@gmail.com
 Service Change Form

BIll Cycle * Monthly

Bimonthly

Quarterly

Halfyearly

Yearly

Notes

Service Account Number

New Installation Information

Address * PERUMAHAN BUKIT CITRA DARMO

Street Address

BLOK CD C-15
Building Name

Benowo
District/Kecamatan

Sememi
Subdistrict/Kelurahan

Province * JAWA TIMUR

City * 60198

Network Delivery FTTH GPON

FTTH EPON

METRO GPON

METRO ETHERNET

Other
 Service Change Form

Relocation Fee 0
Exclude Tax

Relocation Date 01-Oct-2022

dd-MMM-yyyy

Identity Card

KTP_YOGY_OLD.jpeg

Signature *

• We hereby confirm that the information above is true and agree to be bound by Biznet’s
Terms and Conditions w hich w ritten and signed on Order Form.