PT. INFOKOMELEKTRINDO
MNC Tower 10th , Jl. Kebon Sirih No 17-19
Jakarta Pusat 10340, Indonesia
Phone: (+62-21) 392 6933 Fax: (+62-21) 392 6911
ORDER FORM – INTERNET SERVICE
Note: Please provide detailed information so we can provision the service faster.
CUSTOMER INFORMATION
Company Name/Customer Name:
Address:
Contact Person:
Contact Title:
Phone:
Fax:
Mobile:
Email:
BILLING INFORMATION
Billing Address:
For Technical inquiries or installation, please contact:
Technical Contact Person:
Phone: 021-392 0220
Fax: 021-392 9935
Mobile:
Email :
Billing Contact Person:
Billing Contact Email:
Billing Contact Phone:
Billing Contact Fax:
SERVICE INFORMATION
Service Type:
Service Capacity:
International Bandwidth
Upgrade
Leased Line (Local Link)
Downgrade
Wireless
__P-to-P __ P-to-M __ M-to-M
Others :
Dismantle
512 Kbps
5 Mbps
20 Mbps
Others (please specify):
1 Mbps
8 Mbps
25 Kbps
Ratio 1 : 1
Trial 1 (one) Week
2 Mbps
10 Mbps
30 Mbps
4 Mbps
15 Mbps
Service Request Date:
Contract Terms : 12 (twelve) month period
Monthly Fee:
One Time Setup Fee:
Infokom Order Form – Internet Service
Page 1 of 2
INSTALLATION INFORMATION
Address - Node A
Address – Node B
Cyber Building
Infokom Elektrindo
Contact Person – Node A
Contact Person:
Phone:
Fax:
Mobile:
Interface Type – Node A
Optical: [ ] SC [ ] ST
Electrical: [ ] RJ-45
Additional installation information:
Contact Person – Node B
Contact Person:
Phone:
Mobile:
AUTHORIZATION
I/We hereby confirm that the information above is true and agree to be bound by INFOKOM’s Terms and Conditions. INFOKOM
has the right to refuse this application without any explanation. INFOKOM’s Terms and Conditions may change at anytime
without prior notice.
Signature & Company Stamp
Print Name:
Date:
INTERNAL USE
Account Manager:
Infrastructure Engineer:
Billing :
Legal :
VP ISP Business Unit
Signature
Date
Signature
Date
Signature
Date
Signature
Date
Signature
Date
PO
BAIJI
INVOICE
PKS
WO
PNL
Please attach the following copies:
1. Tax ID/NPWP for Corporate Customer, KTP/Passport/ID Card for Personal Customer
Infokom Order Form – Internet Service
Page 2 of 2