Opening Hours : 10am - 10pm
Family Entertainment & Lifestyle Centre
Thu, 25 April 2019
Food Centrum
FORMULIR KEANGGOTAAN
MEMBERSHIP FORM
NAMA LENGKAP
Full Name
TEMPAT LAHIR
Place of DOB
TANGGAL LAHIR
Date of Birth
JENIS KELAMIN
Sex
Pria/Male     Wanita/Female
PEKERJAAN
Occupancy
STATUS PERNIKAHAN
Marital Status
Belum Menikah/Single     Menikah/Married
KEWARGANEGARAAN
Nationality
AGAMA
Religion
JENIS IDENTITAS DIRI
Identity
KTP     PASSPORT     KITAS     KIMS     Lain-lain
NOMOR IDENTITAS
ID Number
BERLAKU SAMPAI
Valid Until
NOMOR YANG DAPAT DIHUBUNGI
Contact Number
TELEPON
Telephone
FAX
Facsimile
TELEPON GENGGAM
Handphone
ALAMAT SURAT MENYURAT
Correspondence Address
ALAMAT EMAIL
Email Address
PT. NUSAPLAZA INDAH
Food Centrum, Lantai 3 (Roof Top). Kompleks Rukan Puri Mutiara Blok BA-BB-BC
Jl. GriyaUtama, Sunter - Jakarta 14350. Telp : (021) 2968 9888 - Fax : (021) 2968 9887 - Email : info[at]foodcentrum.com
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