Order Form Bandwidth on Demand

Order Form Biznet Data Center

Note: Please provide detailed information so we can provision the service faster. Please scan & email the Order Form, or fax to +62-21-5700580. / Sales Code

Customer Information

Company Name/Customer Name:
Address:
Contact Person: / For technical inquiries or installation, please contact
Contact Title: / Technical Contact Person:
Phone: / Phone:
Fax: / Fax:
Mobile: / Mobile:
Email: / Email:

Billing Information

Billing Address:
Billing Contact Person: / Billing Contact Fax:
Billing Contact Title: / Billing Contact Email:
Billing Contact Phone:
ID No (KTP/Driver License): / NPWP/Tax ID:

For payment with credit card, please fill the information

Credit Card Type: Master Card/Visa / Credit Card No:
Credit Card Name: / Credit Card Exp Date:

Service Information

Data Center Location: / [ ] MidPlaza [ ] Biznet Technovillage [ ] Bali*
Service Type:
(*) Services that Bali Data Center provided / [ ] Suite/Secure Cage. Dimension: [Length _____ m x Width _____ m] = Area _____ m2
[ ] Closed Rack Space [ ] 14U [ ] 21U [ ] 42U*
[ ] Bundle Closed Rack Space 42U + Power 10A – 220V*
[ ] Bundle Closed Rack Space 42U + Power 20A – 220V*
[ ] Bundle Closed Rack Space 42U + Power 32A – 220V*
[ ] Shared Rack Space ____U
[ ] Secure Cage Space _____ m2 (Midplaza)
[ ] Secure Suite Space _____ m2 (Technovillage)
[ ] Open Space _____ m2
[ ] Rack 42U Rental _____ Unit
[ ] Additional Power: ____ Watts ______A*
[ ] Cross Connect Cable [ ] UTP [ } Fiber Optic
[ ] Others: ______
Monthly Fee : / One Time Setup Fee:
Other Service Information
Apakah perusahaan Anda saat ini menggunakan layanan Biznet? / Is your company currently using Biznet services?
Service Capacity : / Postpaid Biznet Dedicated Internet & Biznet DataComm
Prepaid Biznet Metronet
Biznet Cable TV Office
Lainnya, sebutkan:
ID Pelanggan Biznet / Biznet UserID :

Technical Installation Information

Contact Person: / Additional Installation Information
Name:
Phone:
Mobile:
Email:

Authorization

I/We hereby confirm that the information above is true and agree to be bound by Biznet Data Center Terms and Conditions and we are the authorized to signed the services Order Form. Biznet has right to refuse this application without any explanation. Biznet Data Center Terms and Conditions can change anytime without further notice. For credit card payment, I/We hereby authorize Biznet to charge the credit card for service charge I/We chose / Signature & Company Stamp Print Name:
Date:

Internal Use

Account Executive / Supervisor / Branch Manager / Provision Engineer
Date / Date / Date / Date

Please attach the following copies

[ ] Tax ID/NPWP for corporate customer, KTP/Passport/ID Card for personal customer

[ ] Credit Card (Front & Back) for payment with credit card only

PT Biznet Data Center - Biznet Data Center Order Form - Confidential Information 12/21/2017