Membership Form :

Full Name :

Date of Birth :

ex: 17-8-1945

Religion :

Address :

Postal Code :

Phone :

Cellular Phone :

Email Address :

Office Name :

Office Address :

Office Phone :

Office Fax :

Car Type / Year :

Note :

Transfer to :
BCA PONDOK INDAH
CV BERKAH REZEKI REFI AUTO
Acc : 2373014664
Fax to: (021) 5329388, Attn. Rusdi or Send the email of Transfer Receipt to refiauto@yahoo.com