DIREKTORAT STANDARDISASI
DIREKTORAT JENDERAL POS DAN TELEKOMUNIKASI
Jl. Medan Merdeka Barat 17
Jakarta 10110, Indonesia
DIREKTORAT JENDERAL POS DAN TELEKOMUNIKASI
Jl. Medan Merdeka Barat 17
Jakarta 10110, Indonesia
FR.PM 5
CERTIFICATION FORM | ||||
*Government *Company *Personal | ||||
DATA OF APPLICANT | ||||
1. | Name of Institution/Company/Personal : | |||
2. | Address : | Phone Fax Post Code | : : : | |
3. | Name and Position of Applicant: | |||
4. | Address : | Phone Fax Post Code | : : : | |
DATA OF EQUIPMENT | ||||
5. | Name of Equipment : | |||
6. | Brand of Product : | |||
7. | Model/Type : | |||
8. | Manufactured by : Origin Country : | |||
9. | Manufacturer Address: | Phone Fax Post Code | : : : | |
10. | Note : fill this section if there are any arrangements for certification holder other than information stated above | |||
(place, date) .…………………………………….
(Signature)
(name) _________________________
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