Online Registration Form
Personal Data Of The Customer
Full Name :
Place / Date of Birth :
Invoicing Address :
No. KTP / SIM / Paspor :
Home Phone / Fax :
Work Phone / Fax :
Mobile Phone :
Data Of The Company
Company Name :
NPWP Number :
Contact Person :
No. KTP / SIM / Paspor :
Position :
Company Address :
Office Phone / Fax :
User Name & Password
 (fill with character 'a' - 'z', '0' - '9'. Minimum 5 character, maximum 10 character)
Username 1 :
Username 2 :
Password :
The Payment
Cash Transfer Bank
Bank BALI cabang Ketapang 
Komplek Ketapang Indah
Jl. KH. Zainal Arifin Blok B2 No.9 
A/C # 0901190305
a/n PT. Usaha Mediantara Intranet

Bank BCA cabang Ketapang
Komplek Ketapang Indah
Jl. KH. Zainal Arifin Blok B A / 3-4 Jakarta
A/C # 4013001491
Package Type
(Jakarta Package)
Package
Max. Hour Registration
Fee		 Monthly Fee
(Prepaid)
Standard 40 Hour Rp. 50.000 Rp. 100.000
Superior 100 Hour Rp. 50.000 Rp. 225.000
Unlimited - Rp. 50.000 Rp. 450.000
* Subjet to PPN 10%

(ISDN Package - Jakarta)
Package Max. Hour Registration Fee
& Set Up 		Monthly Fee
(Prepaid)
Superior 100 Hour Rp. 500.000 Rp. 900.000
Unlimited - Rp. 500.000 Rp. 1.800.000
* Subjet to PPN 10%

STATEMENT

I / We declare that all the information that given is true and agree for all condition that given by SpotNet (PT. Usaha Mediantara Intranet). I / We give the trustee to PT. Usaha Mediantara Intranet to change the account of the credit card (Visa / Mastercard) connection with the payment of the monthly fee and the internet subscribing registration (SpotNet).


©1999 PT. Usaha Mediantara Intranet. All rights reserved
Gajah Mada Tower 4th Jl. Gajah Mada No.19-26 Jakarta 10130
Phone : (62-21) 6345005 Fax : (62-21) 6345358