Agen Pos+Form
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Transcript of Agen Pos+Form
FORMULIR PENDAFTARAN AGENPOS DATA PRIBADI
1. 2. 3. 4. 5. 6. 7. 8.
Nama sesuai dengan KTP/SIM No KTP/SIM (Lampirkan fc) Jenis kelamin Tempat/Tanggal lahir Alamat saat ini Alamat E-mail Telepon rumah/kantor Telepon genggam/Hp
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INFORMASI BADAN USAHA / PERORANGAN
1. 2. 3. 4. 5. 6. 7. 8. 9.
Nama Badan Usaha/Perorangan Alamat Badan Usaha/Perorangan Nomor NPWP Jenis Usaha No Telepon Fax Kantor Email Kantor Kantorpos Penghubung (Kprk) Jarak ke Kprk
: : : : : : : : :
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SYARAT-SYARAT KEAGENAN / LAMPIRAN
1. 2. 3. 4. 5. 6. 7.
Formulir pendaftaran Agenpos Fc Surat keterangan domisili usaha Fc NPWP Fc KTP/Tanda pengenal Pas Fhoto 3x4 Denah lokasi Agenpos Lokasi strategis/Ukuran denah
* ) Coret yang tidak sesuai
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Terlampir tidak * Terlampir tidak * Terlampir tidak * Terlampir tidak * Terlampir tidak * Terlampir tidak * 1. Jalan utama 2. Pusat perbelanjaan 3. Jalan protokol 4. Gedung pemerintahan 5. Perumahan
…………….,...........................2010
Pemohon,
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Pas Foto Berwarna
3 X 4