SM Division - PT. Pamapersada Nusantara

A. SUPPLIER ADDRESS (Alamat Pembayaran Supplier)

STATUS : INCOMPLETE / ̶C̶O̶M̶P̶L̶E̶T̶E̶

Country *
(Negara)

Region *
(Kawasan)

Holding Company / Group
(Perusahaan Induk/Group)

Company Name *
(Nama Perusahaan)

Company Director *
(Direktur Perusahaan)

Company Address *
(Alamat Perusahaan)

City *
(Kota)

Other City *
(Kota Lainnya)

ZIP / Post Code
(Kode Pos)

RFQ Number Refference
(Referensi no. RFQ Pama)

Contact Name 1 *
(PIC Name)

Mobile Phone 1 *
(No. Handphone)

E-mail Address 1 *
(Alamat Email)

Contact Name 2
(PIC Name)

Mobile Phone 2
(No. Handphone)

E-mail Address 2
(Alamat Email)

Office Phone *
(No. Telpon Kantor)

Fax
(No. Faximile)

Tax Register No. *
(NPWP – Nomor Pokok Wajib Pajak)

Term of Payment *
(Jangka waktu pembayaran)

E-Credit Limit Value
(Batas Nilai Hutang)

B. Supplier Payment Address (Alamat Pembayaran Suppier)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

Responsible Account *
(Penanggung Jawab Rekening)

Bank Account Name 1 *
(Nama Rek Bank)

Bank Name *
(Nama Bank)

Bank Address / Branches *
(Alamat Bank / Cabang Bank)

Bank Account Number *
(No. Rekening Bank)

Currency *
(Mata Uang)

Bank Account Name 2
(Nama Rek Bank)

Bank Name
(Nama Bank)

Bank Address / Branches
(Alamat Bank / Cabang Bank)

Bank Account Number
(No. Rekening Bank)

Currency
(Mata Uang)

C. Business Information (Informasi Usaha)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

Number of Employee
(Jumlah karyawan)

Turn Over per Year
(Jumlah Penjualan Pertahun)

Name Three Current Client
(Tiga Nama Klien saat ini )

D. Commodity Group Code (Jenis Barang)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

Commodity 1 *

Commodity 2

Commodity 3

Commodity 4

E. Supplier Type (Spesifikasi Usaha)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

Supplier Type 1 *

Supplier Type 2

Supplier Type 3

Supplier Type 4

F. Main Product (Brand Supplier)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

Product / Brand 1 *

Product / Brand 2

Product / Brand 3

Product / Brand 4

G. Quality Accreditation (Akreditas Kualitas)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

Quality Description
(Deskripsi Kualitas)

Accreditation Authority
(Otoritas Akreditasi)

Certificate Number
(Nomor Sertifikat)

Effective Date
(Tanggal Effective)

Expired Date
(Tanggal Berakhir)

H. Attachment (Lampiran)

1. Foto Kantor / Warehouse / Company Profile *

2. Akta Perusahaan *

3. Surat Pengesehan Kehakiman (Khusus PT) *

4. Surat Izin Usaha Perdagangan (SIUP) *

5. Tanda Daftar Perusahaan *

6. Nomor Induk Wajib Pajak (NPWP)*

7. Surat Pengukuhan Pengusaha Kena Pajak (SPPKP)*

8. Surat Keterangan domisili perusahaan /SITU/Ijin Gangguan*

9. Bukti Penerimaan surat , surat setoran Pajak (SSP), SPT Masa dan lampiran Pajak Keluaran

10. Bussiness Integrity Statement (Integriry Pact) for Pama’s Supplier*

FORM SUPPLIER REGISTRATION - PT. PAMAPERSDA NUSANTARA - SUPPLY MANAGEMENT DIVISION

A. SUPPLIER ADDRESS (Alamat Pembayaran Supplier)

STATUS : INCOMPLETE / ̶C̶O̶M̶P̶L̶E̶T̶E̶

B. Supplier Payment Address (Alamat Pembayaran Suppier)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

C. Business Information (Informasi Usaha)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

D. Commodity Group Code (Jenis Barang)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

E. Supplier Type (Spesifikasi Usaha)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

F. Main Product (Brand Supplier)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

G. Quality Accreditation (Akreditas Kualitas)

STATUS : INCOMPLETE / C̶O̶M̶P̶L̶E̶T̶E̶

H. Attachment (Lampiran)

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SURAT PERNYATAAN