FORMULIR PENDAFTARAN RESELLER
DATA KONTAK
Nama *
Your answer
Jenis kelamin *
No KTP *
Your answer
Alamat KTP *
Your answer
No HP/Whatsapp *
Your answer
Alamat Email *
Your answer
DATA REKENING
Nama Bank *
Your answer
Nama Pemegang Rekening *
Your answer
Nomor Rekening *
Your answer
ALAMAT UNTUK PENGIRIMAN
Nama Jalan/Gang *
Your answer
Nomor *
Your answer
RT dan RW *
Your answer
Kelurahan & Kecamatan *
Your answer
Kabupaten & Kode Pos *
Your answer
Patokan alamat pengiriman *
misalnya : 100 meter dari Indomaret, samping bengkel motor , dekat rumah makan Padang, dll
Your answer
TERIMA KASIH
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