Client Registration Form
Complate all data below. Mark (*) meaning must be fill.
1. User Autentication
Username * minimal 5 character!
Password * min 4 digit (character+number)!
Confirm Password * confirm your password !
Email * cth: info@yahoo.com
confirm Email * Confirm your Email !
2. Personal Informations
Full Name *
Address *
City *
Province *
Portal Code
Phone cth: 02172555666
Fax cth: 02172555666
Handphone * cth: 081322555666
Place/Date of Birth
Gender M / F
3. Additional Fields (Others)
Bank Name* cth: BCA , MANDIRI , BNI
Account No. *
Account Name *
information from
Type the Captcha * security image    

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