GERBANGAKSES INDONESIA
Jl. Teuku Umar Barat No.335, Padangsambian
Kec. Denpasar Barat - Bali 80113
USER INFORMATION
Name
Job Title
Gender
Male
Female
Phone
Email
IDCARD INFORMATION
Idcard Type
KTP
Passport
Other
Idcard Number
ID Card
COMPANY INFORMATION
Company Name
Npwp
Npwp Name
Line Bussines
Phone
Address
Website
ADMINISTRATION INFORMATION
Administration Person
Department
Address Technical
Phone
Technical Contact
Department Technical
Phone Technical
Email Technical
SERVICE INFORMATION
Speed
Address Installation
Setup Fee
Monthly Charge
Service Start
Proposal Number
Kirim
Kembali
