SUPPLIER REGISTRATION FORM
Company Information
Company Name : _______________________________________________________________ (PT / CV / Individual / Others)*
Address : __________________________________ Postal Code : __________________________________
City : __________________________________ Country : __________________________________
Phone/ Fax No : ________________ /_________________ Website : __________________________________
Supply : Goods (Spare parts / Oil & Gas / Fuel / Stationery / IT / Household)*
Services (Transporter / Vehicle Rental / Outsource / Insurance / Repair & Mtn ___________________)*
Others ____________________________________________________________ (include investments)
Ownership : Local PMA Joint Vtr Others _________________________________________
PIC Marketing : Name _____________________________________ Title _________________________________________
E-mail ________________________ Phone/ HP/ Fax No ___________ ext. ____ /__________ /__________
Financial Information
Currency : IDR Currency : USD Others __________
Bank : __________________________________ Bank : __________________________________
Branch : __________________________________ Branch : __________________________________
Account No : __________________________________ Account No : __________________________________
Beneficiary Name : __________________________________ Beneficiary Name : __________________________________
Address : __________________________________ Address : __________________________________
Term of Payment : 30 days 45 days 60 days Others __________________ days (after invoice received)
Credit Limits : Rp. _____________________________________________________________________________ per month
Bank Reff. Letter : __________________________________________________________________________________ (If any)
PIC Finance-Billing : Name _____________________________________ Title _________________________________________
E-mail ________________________ Phone/ HP/ Fax No ___________ ext. ____ /__________ /__________
1• In case of Beneficiary Name is not the same with Company Name, Vendor has to submit Statement Letter.
Legal & Taxes Information
Trade Business Lisc. : ___________________________________________________________________________________ (SIUP)
Coy Reg Code : ____________________________________________________________________________________ (TDP)
Tax Reg Code : __________________________________________________________________________________ (NPWP)
SKT No : _________________________________________________________________ (Surat Keterangan Terdaftar)
SKPPKP : _____________________________________________(Surat Keputusan Pengukuhan Pengusaha Kena Pajak)
Pengurus/Direksi Masa Jabatan : _______________________________________________________________________________
Pesero Komanditer/Komisaris Masa Jabatan : ______________________________________________________________________
Pemegang Saham : 1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
Pendirian Perusahaan : No. Akta :____________________________________ Tanggal : _________________________________
Notaris : ____________________________________
Pengesahan Menteri Hukum dan HAM :
No.AHU : ____________________________________ Tanggal : __________________________________
Perubahan Sesuai UU No.40/2007 :
No.Akta : ____________________________________ Tanggal : __________________________________
Notaris : _____________________________________
Persetujuan Menteri Hukum dan HAM :
No.AHU : _____________________________________
Keterangan / Catatan mengenai yang berhak dan berwenang mewakili perusahaan sebagaimana diatur dalam Anggaran Dasar Perseroan :
Establishment Deed : _________________________________________________________________________________________
PIC Accounting-Tax : Name _____________________________________ Title _________________________________________
E-mail ________________________ Phone/ HP/ Fax No ___________ ext. ____ /__________ /__________
1• In case of Vendor is not PKP (Pengusaha Kena Pajak), Vendor has to submit Statement Letter of Non PKP.
2• All the Legal & Taxes documents have to be copied and submitted.
3• In case of changes in Shareholder, Latest Shareholder Resolution Deed have to be copied and submitted.
Acknowledge & approved by,
(______________________)
Name :
Title :
Date :
PRO/FRM/004/01/12
Filled by Puninar
Vendor Code : _____________________________________________________________________________ (Procurement)
Input By, Checked by,
(______________________) (______________________) (______________________)
Procurement Finance Dept Legal Dept
For further information, please contact:
PUNINAR LOGISTIC
Jl. Raya Cakung Cilincing KM 1,5, Cakung, Jakarta Timur 13910
Phone: 021-4602278 Fax: 021-46835553
E-mail:
[email protected] (Procurement Dept.) and
[email protected] (Finance & Treasury Dept.)
* Cross if not necessary. PRO/FRM/004/01/12
