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To: MR. JOSEPH WIDYANTA SA
EC Investment
Fax +62-21-7452860
(Please fills with the capital block letter clearly)
Personal Data (This information will be stated on the Certificate of Investment)
Full name as printed on ID card
:____________________________________
Date of birth : (d)______(m)______________(y)___________Occupancy:__________________
Sex : ____________ ID card
number:_______________________________
Address:
__________________________________________________________________
City:__________________________State/Province:__________________________
Zip Code:____________
Country:_______________________________________
Telephone no:________________________Fax no:____________________________
E-mail address: _____________________________________
Repay Method
(This method is very importance to return your
investments back!! EC Investment responsible for the transfer fee
only)
Bank Account
Bank account number:_______________________________
Name on account:____________________________________
Bank name :____________________________
Bank address:____________________________________________
Charity Program
O Yes,
I want to donate from my investment of_______percent to EC
Investment for social fund (min 0,2%)
O No,
I don't.
I suggest using the social fund for _____________________________________________
Amount of Investment
(For multi investment please specify each investment detail)
| No | Investment code | Amount of investment | Currency of repay |
Total amount of transferred : _________________________
Currency : _________________
Date of transferred : (d)_____(m)____________(y)_______
Source bank:______________
I hereby certify that all the information above are true, and I agree to invest on EC Investment.
_________________
(Investor Signature)
This form is not valid without Investor signature.
__________________________________(Please cut here !)________________________________
Please print and full fill this Investment Application Form accompanied by copy of transfer voucher and send to:
Mr. Joseph
Widyanta
EC Investment
Jl Kesejahteraan No 24
Jakarta Barat
Indonesia 11130
Telephone:
+62-21-6329505
Fax: +62-21-7452860
E-mail : jwidyanta@yahoo.com
EC Investment not responsible for any disadvantage caused by send this information through the internet media. EC Investment only suggests to use Fax or Express Mail Service. The confirmation e-mail will be sent to your e-mail address after the application form received.
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