STK REPLACEMENT REQUEST FORM

Doc No. :
Date :

Request Type : Replace V-Tri (to replace damaged/lost/stolen STK) - via 3Store
Change STK Ownership - via H3I HO

Distributor Name : PT. BETA TECNOLOGI INDONESIA

Distributor STK MSISDN : 089635013650
Distributor Contact Name : Rahmat Mulyono
Distributor Contact Phone : 089635011389

Current STK Ownership ( If change ) :

Retailer Name :
Retailer STK MSISDN :
Retailer Contact Name :
Retailer Contact Phone :
Retailer Address :
( Including Kecamatan ) :

Remarks / Reason for Request

STK last remaining credit balance*:

*Note: the above remaining credit balance of 'blocked' STK as in system (HCPT BM)

Requested By, Received By, Performed By,

( ) ( ) ( )
Distributor Branch Sales Manager H3I Helpdesk / 3Store Agent
Date : Date : Date :