SolindoHost :: Registration

Make Your Web Happy

Registration

Please, feel free to fill this form :

Step 1: Data Pelanggan/Customer Data


Full Name:*	Referensi ID:

Place & Date of Birth:*	E-mail:*
(yyyy-mm-dd)
Address:*	City:

	Province:

	Country:

Phone:*	Fax:

Handphone:	ID. Card Number:

Step 2: Keanggotaan Perusahaan/Company Membership


Company Name:*	NPWP/Akte/SIUP:*

Billing Address:*	City:

	Province:

	Country:

Phone:*	Fax:

E-mail:*

Jenis Layanan/Services


Services:*	Packages:*

Nama Domain/Domain Name Services

Status:*

Domain Name:*

New Register Renewal Transfer

www.

Term:*

1 Year3 Year5 Year10 Year

Pilihan ID & Password CPanel Hosting/ID & Password Choice Hosting CPanel


1st Choice:*	2nd Choice:*

Password:*

Pilihan ID & Password E-mail/ID & Password Choice E-mail


First Email:*	Password 1:*

Second Email:*	Password 2:*

Pembayaran/Method Of Payment

Tunai/Cash Giro Transfer ATM BCA Klik BCA

Kode Keamanan/Security Code

Pernyataan/Statement

I hereby confirm that the information here in give is correct and agree to be bound by all terms, condition and policy

Yes, I Agree

Contact Information
Jl. Perak Timur No. 62
Surabaya 60164
Jawa Timur-Indonesia
Phone: +62-31-355 0967
Fax: +62-31-353 7566
Email: cs@solindohost.com

Payment

Bank BCA
No. 088-4631-528
a/n Prasetio Tjondrokusumo

Bank Mandiri
No. 140.000.770.2120
a/n Prasetio Tjondrokusumo

UOB - Singapore
No. 380-392-741-1
a/n Prasetio Tjondrokusumo

CS 02

CS 01

Server Admin