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Formulir Pendaftaran Agen
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* Indicates required question
Nama Lengkap
*
Your answer
Nama Toko / Outlet
*
*nb : Tulis nama Anda bila toko Anda belum memiliki nama
Your answer
No. Telp WA (Aktif)
*
Your answer
Alamat Lengkap Agen
*
Your answer
Kelurahan Agen
*
Contoh : Petompon
Your answer
Kecamatan Agen
*
Choose
Banyumanik
Candisari
Gajahmungkur
Gayamsari
Genuk
Gunungpati
Mijen
Ngaliyan
Pedurungan
Semarang Barat
Semarang Selatan
Semarang Tengah
Semarang Timur
Semarang Utara
Tembalang
Tugu
Bersedia Untuk Menjualkan Produk Air Mineral Moedal
*
Ya
Tidak
Produk Yang Bersedia Untuk Dijual
*
Botol 250 ml ( isi 48 botol per dus)
Botol 330 ml ( isi 24 botol per dus)
Botol 500 ml ( isi 24 botol per dus)
Galon 19 liter (sistem pinjam galon)
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