Biznet | Customer Registration

Biznet Order Form

Order Date *

VAT/PPN *

With Holding Tax/PPh 23 *

Bill Cycle *

Term Of Payment

Currency *

SERVICE INFORMATION

Service *

Biznet Dedicated Internet Service Capacity *

Biznet Educationnet Service Capacity *

Biznet Healthnet Service Capacity *

Service Type Biznet DataComm *

Biznet DataComm Service Capacity *

Biznet Internet Exchange Service Capacity *

Biznet Hospitality Service Capacity *

Biznet Bandwidth on Demand Service Capacity *

Biznet Manage WiFi

IPv6 Addressing

Technical Support In Charge

Add-on IP Public

Until*

Total*

BoD Fee*

Contract Terms (min 12 months)* Contract Terms (min 24 months)* Contract Terms (min 36 months)*

Monthly Fee (excl. Tax)*

Yearly Fee (excl. Tax)*

One Time Setup Fee (excl. Tax)*

Network Delivery

Network Delivery Node B

Numbers of Access Point for Free Biznet Hotspot *

AS Number*

Router IP Address*

Routes to be Announced*

Routes to be Received *

Router Type*

Router Interface Card*

Memory*

OS Version*

Service Type *

Current IP Address*

Additional IP Address Assigned*

Amount of New IP Address Assigned*

Additional Monthly Fee*

Service Request Date

Effective Date*

Notes

Service Information*

Service Notes

CONTACT DETAIL

ID Country *

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ID Type *

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ID Number *

Please attach Tax ID/NPWP*

First Name *

Last Name *

Select Gender *

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Date Of Birth

COMMUNICATION DETAIL

Mobile Number *

Home Number

Email *

Preferred Language *

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INSTALLATION ADDRESS

Find Address / Property

Please follow the address structure examples as written below and match it as you type or input the data.

1. Building & Apartment / Property Name

- APARTEMEN JEMBER TOWN SQUARE - TOWER B LT 1 UNIT 15

- APARTEMEN JEMBER TOWN SQUARE - UNIT A12

- DREAMLAND CLUSTER KAV 17

- BANK JATIM CABANK BANYUWANGI CABANG INDUK

2. Main Street

- JL JOYOBOYO NO 635

- JL A YANI GG 1 NO 1

- JL KARANG INDAH TIMUR GG SEJAHTERA BLOK B NO 1

- JL ALAMANDA PREMIER - BLOK A NO 3B

3. Complex Name / Store

- PERUMAHAN JAYALAND PURI SURYA JAYA TERRACE - BLOK CC3 NO 26

- PERUMAHAN WISMA KATANG GG 2 NO A12

- PERUMAHAN LATIFA BOULEVARD NO 15

- PERUMAHAN BUMI LAMONGAN RAYA

Address 1

Sub District

Address 2

District

Address 3

City

Postal Code

Address 4

State

Country

Address 5

INSTALLATION NODE B ADDRESS

Set Equal To Installation

Find Address / Property

Address 1

Sub District

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Address 2

District

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Address 3

City

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Postal Code

Address 4

State

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Country

Fetching data

Address 5

IDENTIFICATION ADDRESS

Set Equal To Installation

Find Address / Property

Address 1

Sub District

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Address 2

District

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Address 3

City

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Postal Code

Address 4

State

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Country

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Address 5

BILLING ADDRESS

Set Equal To Installation

Find Address / Property

Address 1

Sub District

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Address 2

District

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Address 3

City

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Postal Code

Address 4

State

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Country

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COMMUNICATION BILLING DETAIL

First Name *

Last Name *

Mobile Number *

Home Number

Email *

TECHNICAL CONTACT PERSON

First Name *

Last Name *

Mobile Number *

Home Number

Email *

MARKETING INFORMATION

Salescode Branch

Salescode Sales Digital

How do you know Biznet? *

Signature*