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FORMULIR PENDAFTARAN ORIFLAME
* wajib diisi dengan benar
1.	Nama *
2.	Jenis Kelamin (L/P) *
3.	Alamat Lengkap (termasuk RT/RW) *
4.	Kota * *
5.	Kode Pos * *
6.	Alamat Kantor / Pengiriman lain (jika ada)
7.	No. KTP / SIM * *
8.	Salinan (fotokopi) KTP / SIM (.jpg,.gif) * *
9.	No. Telp / HP (yang bisa dihubungi) * *
10.	Website / Blog (jika punya)
11.	No. Rekening Bank (harus atas nama pribadi) *
12.	Nama Bank *
13.	Kantor Cabang * *