bahan administrasi

1. PRIMAMANDIRI
Jalan Jendral Ahmad Yani No. 2 Tabat Kab. Langkat – Sumatera Utara 20854
Telepon : 061 75002152 – 75025022 e-mail : info_primamandiri@yahoo.com
FORMULIR PENDAFTARAN
Data Pribadi
Nama / User Name : ______________________________________________________________
No. KTP : ______________________________________________________________
Password : ______________________________________________________________
Retype Passwor : ______________________________________________________________
Introducer Id : ____________________________ ____________________ ID Penempatan
ID Distributor New : _____________________________________________________________
Paket Produk : A. PAKET 1 Rp. 1.500.000,- [Kompor Gas / Handphone]
B. PAKET 2 Rp. 2.000.000,- [TV 21 Inc / Kulkas 1 Pintu atau Mas 22 2 Gram]
C. PAKET PROGRAM [Harga / Jenis Program sesuai ketentuan]
Alamat Lengkap : ________________________________________________________________
( Kirim Barang ) ______________________________________ Kode Pos : ________________
Telepon Rumah : _____________________________
Telepon Kantor : _____________________________
Telepon HP : _____________________________
Email : _____________________________
Pekerjaan : _____________________________
Kontak Person : _____________________________ Terdaftar Tanggal :
Data Bank
Di Input Oleh :
Nama Bank : _____________________________
Cabang/Unit : _____________________________
( _________________ )
Nomor Rekening : _____________________________
Pemilik Rekening : _____________________________
Calon Distributor, Referensi - Closing
( __________________________ ) ( __________________________ )
www.primamandiri.com