BismillahirrohmanirrahimDATA PELANGGAN

1. Nama : .....................................................................................................

2. Alamat : .....................................................................................................

3. Telp. : .....................................................................................................

4. No. HP Layanan : ..............................................

5. Jenis Layanan (lingkari) : 1. Biasa 2. Plus Group Ikhwan 3. Plus Group Ummahat

6. Berlangganan mulai bulan : ...........................................

Bontang, .................................... 2009

Pelanggan

(___________________)

KWITANSI PEMBAYARAN

Telah terima dari :

Nama : .........................................................................................................................

No. Pelanggan : ................... No. HP Layanan : ...................................................................

Uang sebesar : Rp....................................................................................................................

Untuk pembayaran biaya berlangganan bulan :.....................................................................................

Terbilang :

Bontang, ...........................2009

Penyetor Petugas

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Lembar untuk An-Nashihah

KWITANSI PEMBAYARAN

Telah terima dari :

Nama : .......................................................................................................................

No. Pelanggan : ................... No. HP Layanan : ...................................................................

Uang sebesar : Rp....................................................................................................................

Untuk pembayaran biaya berlangganan bulan :.....................................................................................

Terbilang :

Bontang, ...........................2009

Penyetor Petugas

( ) ( )

Lembar untuk pelanggan

Nomer :