Form Sygma RESELLER / MEMBER*

Nama Lengkap                              :_________________________________________________________ _______

Kartu Identitas                               : KTP/SIM/PASSPORT*               No. Identitas: ____________________________

Tempat/Tanggal Lahir                  :_________________________________________              Jenis kelamin : L / P*

Alamat Sesuai Kartu Identitas     :_________________________________________________________ _______

                                                         :___________________________________________ _____________________

Kota                                                 :_____________________________            Kode Pos :_____________________

Alamat Surat Menyurat               :__________________________________ ______________________________

                                                         :_____________________ ___________________________________________

Kota                                                 :_____________________________            Kode Pos :_____________________

Telepon                                          :_____________________________            HP:___________________________

Alamat Email                                  :________________________________ ________________________________

Kewarganegaran                           : WNI/WNA*

NPWP                                             : Ada/Tidak ada*         No. NPWP : _____________________________________

Pekerjaan                                       :__________________________ ______________________________________

Bidang Usaha                                 :_________________________ _______________________________________

Alamat Pekerjaan                         :________________________ _______________________________________

                                                         :___________________________ _____________________________________

Status Perkawinan                        : Belum Menikah/Sudah Menikah*

Pendidikan Terakhir                     :      SMA            D3           S1             S2             S3

Jenis Usaha                                    : ________________________________________________________________

Alamat Usaha                                 : ________________________________________________________________

NPWP                                             : ________________________________________________________________

Mengetahui Sygma Dari              :      Majalah         Koran           Internet          Teman             Spanduk/Leaflet/Brosu

                                                                Lain-Lain (sebutkan): ____________________________

Apakah Anda Mengikuti              : Ya/Tidak* (Mohon sebutkan jika ya)

Komunitas

                                                                                                                                          (__________________________)

print

kirim

cetak

arsip

RSS