PT Veritra Sentosa Internasional
Jl. Soekarno Hatta No. 543A Wisma Ritra Lt.1 Bandung – 40275
1. Data Akun Mitra
Nama Lengkap : ___________________________________________________________________________________
No Identitas : ___________________________________________________________________________________
Jenis Kelamin : ___________________________________________________________________________________
No HP Keagenan : ___________________________________________________________________________________
Email : ___________________________________________________________________________________
Alamat Lengkap : ___________________________________________________________________________________
___________________________________________________________________________________
Kota : ____________________________________ Kode Pos : _____________________
Tempat/Tgl Lahir : ___________________________________________________________________________________
Nama Ahli Waris : ___________________________________________________________________________________
Hubungan : ___________________________________________________________________________________
No Telp/HP : ___________________________________________________________________________________
2. Data Rekening Bank :
BCA Mandiri BSM BNI BRI
No. Rekening : ___________________________________________________________________________________
Atas Nama : ___________________________________________________________________________________
No HP Bonus : ___________________________________________________________________________________
3. Data Sponsor
Nama : ________________________________________ Id Mitra : ______________________
4. Data Upline
Nama : ________________________________________ Id Mitra : ______________________
5. Pilihan Kartu Pin Aktifasi HAK USAHA (HU)
1 HU 3 HU 7 HU
BASIC (Rp.275.000) SILVER (Rp.825.000) GOLD (Rp.1.925.000)
Contac Person : RUSTOMO
Id Mitra : VP8561110
Web Support : http://www.klikvsi.com/?ref=VP8561110
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