Pendaftaran & Konfirmasi Anggota Baru NEC
Registration Form For New Nissan Evalia Community Member
* Sebelum mengisi Formulir ini, silahkan melakukan transfer iuran sebesar Rp. 100.000,- ditambah 3 digit nomor akhir no handphone anda. Ke Rek BRI no 2075.01000.400560 a/n Perkumpulan Nissan Evalia Community . Harap diisi dibagian berita dengan nomor plat mobil anda.

Respon Cepat Terkait Pendaftaran Anggota Baru bisa ke :
Whatsapp : 081211-711-711 (Div. Keanggotaan)

Nama Lengkap / Name : *
Your answer
Tanggal Lahir / Birth Date : *
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Alamat Tinggal / Address : *
Your answer
Kota / City : *
Your answer
Propinsi / provinces :
Your answer
Pekerjaan / Occupation : *
Your answer
Bidang Usaha : *
Your answer
No. HP Aktif / Active Mobile Phone : *
Your answer
No. HP Lainnya / Other Phone Number :
Your answer
No HP WHATSAPP (Jika ada) / Whatsapp Phone Number
Your answer
PIN BB (Jika ada) / Blackberry PIN (if available)
Your answer
No. Plat Mobil / Car Plate Number : *
Your answer
Warna Mobil / Car Color : *
Email : *
Your answer
Jika Darurat dapat menghubungi ? Isi dengan nama / Contact Name in Emergency Situation *
Your answer
No Kontak Darurat (HP/Rumah) / Emergency Number to Contact *
Your answer
Hubungan / Relationship : *
Required
KONFIRMASI / Confirmation
Tanggal & Jam Transfer / Transfer Date & Hour : *
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Time
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Jumlah Transfer / Amount Of Transfer : *
Your answer
Transfer Dari Bank / From Bank : *
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