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 BCA NEC 252.073.5120 an Dimas Rizal ST. Harap diisi dibagian berita dengan nomor plat mobil anda.

Respon Cepat Terkait Pendaftaran Anggota Baru bisa ke :
Whatsapp : 0811-1554-455 (Div. Keanggotaan)

Nama Lengkap / Name :
Your answer
Tanggal Lahir / Birth Date :
MM
/
DD
/
YYYY
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 :
MM
/
DD
/
YYYY
Time
:
Jumlah Transfer / Amount Of Transfer :
Your answer
Transfer Dari Bank / From Bank :
Submit
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