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FORMULIR PENDAFTARAN AGENPOS DATA PRIBADI

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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

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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

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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

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