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FORM REGISTRASI RESELLER MAK YUS
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* Indicates required question
Nama :
*
Your answer
Tempat / Tanggal Lahir :
*
MM
/
DD
/
YYYY
Jenis Kelamin
*
Pria
Wanita
No. KTP /SIM / Paspor / Kartu Pelajar :
*
Your answer
Alamat :
*
(alamat lengkap)
Your answer
Agama
*
Islam
Kristen
Budha
Hindu
Other:
Pekerjaan :
*
Pelajar
Wiraswata
Pegawai (PNS)
Profesional
Ibu Rumah Tangga
Other:
No Hp :
*
Your answer
No Whatsapp
*
Your answer
E-Mail :
Your answer
Punya Toko Online
*
Ada
Tidak Ada
Nama dan Alamat Toko Online Jika Ada
Your answer
Alasan mengapa ingin menjadi Reseller Rendang Mak Yus
*
Your answer
*
Dengan ini saya bersedia mengikuti aturan dan ketentuan dari Rendang Mak Yus
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