7/26/2019 Formulir Data Pelanggan

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Profl Kelembagaan:

Nama Institusi : ......................................................................

.........Alamat : ......................................................................

.........

NPWP : ......................................................................

.........Jumlah Perwakilan : ......................................................................

.........PIC Perjalanan Dinas : ......................................................................

.........Jabatan : ......................................................................

.........Tempat/Tanggal Lahir : ......................................................................

.........N. Telepn : ......................................................................

.........!a" : ......................................................................

.........N. Telp #eluler : ......................................................................

.........Alamat $mail : ......................................................................

.........

Profl Pimpinan Lembaga:

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

.........Alamat %antr : ......................................................................

.........

Tempat/Tanggal Lahir : ...............................................................................

Alamat $mail : ......................................................................

!rmulir Data Pelanggan &aru'a In'nesia

7/26/2019 Formulir Data Pelanggan

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.........

Data Perjalanan Dinas:

Anggaran (ia)a Jasa Penerbangan per Tahun : ..............................*ata+rata pembelanjaan jasa penerbangan

&aru'a In'nesia per tahun : .............................*ute Penerbangan )ang sering 'iterbangi + Dmestik :

........................................... + Internasinal:

...........................................

Apakah ter'apat kegiatan tahunan )ang menggunakan jasa

penerbangan,

- Ti'ak- a sebutkan:

............................................

#a)a men)atakan bahwa pern)ataan )ang 'iberikan 'i atas a'alahbenar.

................................ ..........................0tempat1 DD/22/

tt'

................................

nama 3 jabatan pemhn'isertai stempel ke'inasan