Trial Form Biznet Dedicated Internet

Note: Please provide detailed information so we can provision the service faster. Please scan & email the Order Form, or fax to +62-21-5700580. / Sales Code

Customer Information

Company Name/Customer Name:
Address:
Contact Person: / For technical inquiries or installation, please contact
Contact Title: / Technical Contact Person:
Phone: / Phone:
Fax: / Fax:
Mobile: / Mobile:
Email: / Email:

Billing Information

Billing Address:
Billing Contact Person: / Billing Contact Fax:
Billing Contact Title: / Billing Contact Email:
Billing Contact Phone:
ID No (KTP/Driver License): / NPWP/Tax ID:

For payment with credit card, please fill the information

Credit Card Type: Master Card/Visa / Credit Card No:
Credit Card Name: / Credit Card Exp Date:

Service Information

We already applied Dual Stack system (IP v4 & v6) on our network and we highly recommend you to add IPv6 to your network. / IPv6 Addresing: [ ] Yes [ ] No
Service Type : [ ] Biznet Dedicated Internet [ ] Others:
[ ] Biznet Metronet [ ] Biznet DataComm
__ P-to-P __ P-to-M __ M-to-M
Service Capacity : [ ] 10 Mbps [ ] 15 Mbps [ ] 20 Mbps
[ ] 25 Mbps [ ] 30 Mbps [ ] 40 Mbps
[ ] 50 Mbps [ ] 100 Mbps [ ] 150 Mbps
[ ] Others (please specify):
Service request date / Trial terms 3 Days
Monthly fee / One time setup fee

Installation Information

Address - Node A / Address - Node B
Contact Person - Node A
Name:
Phone:
Mobile:
Email: / Contact Person - Node B
Name:
Phone:
Mobile:
Email:
Interface Type - Node A
[ ] Optical [ ] Electrical / Interface Type - Node B
[ ] Optical [ ] Electrical
Additional installation information
(Please specify in detail)

Marketing Information

How do you know Biznet?

[ ] Newspaper: / [ ] Biznet Website
[ ] Magazine: / [ ] Search Engine
[ ] Radio: / [ ] Referenced by friend/family/colleague
[ ] Billboard/Baliho / [ ] Others:

Authorization

·  We hereby confirm that the information above is true and agree to be bound by Biznet’s Terms and Conditions which written on the proposal of Dedicated Internet and we are the authorized to signed the services order form.
·  Biznet has the right to refuse this application without any explanation
·  Biznet’s Terms and Conditions may change at any time without prior notice
·  For credit card payment, we hereby authorize Biznet to charge the credit card for service type we chose. / Signature & Company Stamp Print Name:
Date:

Internal Use

Account Manager / Infrastructure engineer / Network engineer / Billing/customer care
Date / Date / Date / Date

Please attach the following copies

[ ] Tax ID/NPWP for corporate customer, KTP/Passport/ID Card for personal customer

[ ] Credit Card (Front & Back) for payment with credit card only

PT Supra Primatama Nusantara - Biznet Dedicated Internet Trial Form - Confidential Information 9/19/2016