Service Change Form

Service Change Form

Customer Information
New Customer Information
Billing Account Number *
N/A
N/A

Same With Previous Customer Information Same With Previous Customer Information
Company Name/Customer Name *
N/A
NPWP/Tax ID *
N/A
NPWP/Tax Address *
N/A
Please attach new Tax ID/NPWP for corporate customer, KTP/Passport/ID Card for personal customer
New Billing Information
N/A

Same With Previous Billing Information Same With Previous Billing Information
Billing Address
N/A

Required Street Address Required Building Name Required City Required Postal Code
Additional Billing Address
N/A

Required District/Kecamatan Required Subdistrict/Kelurahan Required State/Provinsi

Required
Country
Contact Person
N/A

Title Required Full Name
Phone *
N/A

E.g: +62 21998XXX
Mobile *
N/A

E.g: +62 8125578xxxx
Mobile 2
N/A

E.g: +62 8125578xxxx
Email *
N/A
BIll Cycle *
N/A

Monthly
Bimonthly
Quarterly
Halfyearly
Yearly
Notes
N/A

Authorization
Identity Card
N/A
Upload file Capture image using webcam
Please upload your KTP/Identity Card
Signature *
N/A

E-Signature Field
Clear

• We hereby confirm that the information above is true and agree to be bound by Biznet’s Terms and Conditions which written and signed on Order Form.
Verification Code *
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