VENDOR REGISTRATION FORM
FLOW CHART
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VENDOR REGISTRATION FORM
(Questionnaire)
1. COMPANY DETAILS
Company Name (PT/CV/Firma/Koperasi):
Status (Pusat/Cabang):
Street Address
No. tel
fax
email
City
State / Province
Country
Federal Tax I.D Number
Title
No. Tel
No. HP
email
Business Classification-1
Business Classification-2
Business Classification-3
Business Classification-4
Instansi Penerbit
Tanggal Terbit
Masa Berlaku
Contact Person :
Akta Pendirian
No Akta
NPWP dan PKP
No NPWP
No PKP
Bukti Pelunasan Pajak tahun terakhir nomor / tanggl
Laporan Bulanan PPH/PPN tiga bulan terakhir
nomor/tanggal
Surat Izin Usaha Perdagangan (SIUP)
No SIUP
Instansi Penerbit
Tanggal Terbit
Masa Berlaku
Tanggal Terbit
Masa Berlaku
Kualifikasi Perusahaan sesuai SIUP
Tanda Daftar Perusahaan (TDP)
No TDP
Instansi Penerbit
Neraca Perusahaan dan Laporan laba/Rugi .... tahun terakhir yang telah di audit akuntan publik
Tahun Laporan
Nama Akuntan Publik
Sertifikat Keanggotaan KADIN
No. Anggota
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Surat Keterangan Terdaftar BPMIGAS (SKT Migas)
No SKT Migas
Tanggal Terbit
Masa Berlaku
Sertifikat ISO 9000/ISO 18000
No
Instansi Penerbit
Tanggal Terbit
Masa Berlaku
Bagi agen, melampirkan copy surat keterangan keagenan yang masih berlaku yang dikeluarkan oleh Departemen
Perdagangan
Tanggal Terbit
Surat Izin Jasa Konstruksi (SIUJK)
No
Instansi Penerbit
Tanggal Terbit
Masa Berlaku
Daftar susunan Kepemilikan saham (dibuat di atas kop surat perusahaan)
Nama Pemegang Saham Terbesar
Tempat/Tanggal Lahir
Domisili Pemegang Saham
Jumlah Saham (%, Nominal)
Pengalaman dan Daftar Pelanggan
Pelanggan-1/lamanya
Pelanggan-2/lamanya
Pelanggan-3/lamanya
Pelanggan-4/lamanya
2. DETAILS OF OFFICES OR AGENTS
ASIA
Name of Office or Agent
Tel
Fax
Email
EUROPE
Name of Office or Agent
Tel
Fax
Email
MIDDLE EAST
Name of Office or Agent
Tel
Fax
Email
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USA
Name of Office or Agent
Tel
Fax
Email
3. DATA PENGALAMAN PERUSAHAAN (nilai 3 paket tertinggi pengalaman di bidang/
subbidang yang sesuai)
NO
Pemberi Tugas/
Pengguna Jasa
Nama
Paket
Pekerjaan
Bidang / Sub
Bidang
Pekerjaan
Lokasi
2
3
4
1
Tanggal Selesai
Menurut
Kontrak
Nama
Alamat/
Telp
Nomor/Tanggal
Nilai
Kontrak
Berita
Acara
Serah
Terima
5
6
7
8
9
10
4. Data Peralatan/Perlengkapan (hanya untuk jasa pemborongan)
No
Nama
Kapasitas
(output)
saat ini
Jumlah
Merk dan
tipe
Tahun
pembuatan
Kondisi
baik/rusak
Lokasi
sekarang
Bukti
Kepemilikan
5. Data Pekerjaan Yang Sedang Dilaksanakan (hanya untuk jasa pemborongan)
NO
Nama
Paket
Pekerjaan
Bidang/ Sub
Bidang
Pekerjaan
2
3
1
Pemberi Tugas/
Pengguna Jasa
Lokasi
Alamat/
Telp
Nama
4
Kontrak
5
6
No/Tanggal
7
Progres Terakhir
Nilai
Prestasi
Kerja(%)
Tanggal
8
9
6. FINANCIAL
5.1
Turnover for each of the last two years
5.2
Current Asset Value
5.3
Current Liabilities
5.4
Anticipated turnover this fiscal year
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10
5.5
Banking reference
7. PERSONNEL ( no.KTP / contact no./ HP /Email )
5.1
CEO
5.2
CFO
5.3
Sales Manager
8. FACILITIES
7.1
Number of employees
7.2
Average yearly production
7.3
List the work normally subcontracted
7.4
Systems and procedures used to monitor work and suppliers
9. PLANNING
7.1
What planning software do you use ?
7.2
Do you have a Planning manager as a separate
function (YES/NO)
10.
HSE POLICY & PROCEDURES
8.1
Provide tthe following statistics for the past three (3) years:
Lost Time Incidence Rate (Incidentsx200,000/manhours)
(Total Recordable Incidents = Medical Treatment Cases + Restricted
Work Incidents + Lost Time Incidents)
8.2 Have you had any regulatory violations or prosecutions within
the last 3 years ?
8.3
11.
Have you any HSE certification or accreditation ?
GENERAL
9.1
Have you supplied similar services/equipment
corresponding to the above description ?
before
9.2
Provide details of your work experience with JOB PERTAMINA
– TALISMAN JAMBI MERANG, and other major contractors
9.3
In-house design capacity and manpower
10.1 Do you have a Quality Assurance Manual ?
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10.2 Is your Quality System documented with written procedures ?
10.3 Do you have a list of approved sub-vendors ?
12. ETHICS AND COMPLIANCE
11.1 Does your company have a Code of Business Conduct and do
they communicate the elements of the code to their
employees ?
11.2 Does your company conduct periodic business ethics or other
similar audits to assess conformance to the Company Code of
Business Conduct, laws, regulatory requirements, company
policies, and other customer contractual requirements ?
11.3 Does your company have a program and/or procedure for
employees to report their concerns or any instances of ethical
misconduct, while ensuring their confidentiality and protectin
them from any kind of retaliation, if any, as a result of fulfilling
their reporting obligations ?
13. REFERENCES
12.1 Provide details of a Client/Project reference
12.2 Client
12.3 Phone/Fax No.
12.4 Contact person
12.5 Title of Contact person
ADDITIONAL INFORMATION REQUIRED FROM SUBCONTRACTORS AND SERVICES PROVIDERS
14. INSURANCES
13.1 Provide details and values of your current insurance for
13.2 Employers Liability and Workmen’s Compensation (LIMIT $)
13.3 Motor Vehicle Third Party and Passenger Liability Insurance (LIMIT $)
13.4 General Third Party Liability (LIMIT $)
13.5 Equipment Insurance on all equipment owned or leased (LIMIT $)
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13.6 Confirm that your Insurers will waive all rights of subrogation against
PTJM and will name PTJM and their clients as additional insured
(YES/NO)
15. DISPUTES/CLAIMS PENDING
14.1 Give details of any unresolved claims/disputes against clients
14.2 Give details of any claims or litigation pending against your
company
Neraca Perusahaan Terakhir per Tanggal …….. Bulan ……. Tahun ……
(dalam ribuan rupah/satuan US$)
Aktiva
I
Pasiva
Aktiva Lancar
IV
Utang jangka pendek
-
Kas
Rp.
-
Utang dagang
-
Bank
Rp.
-
Utang pajak
Rp.
-
Piutang *)
Rp.
-
Utang lainnya
Rp.
-
Persediaan Barang
Rp.
Jumlah (d)
-
Pekerjaan dalam
Rp.
Rp.
Proses
Jumlah (a)
Rp.
Utang jangka panjang (e)
Rp.
V
Rp.
Kekayaan bersih (a+b+c)-
II
Aktiva Tetap
-
Peralatan dan Mesin
-
Inventaris
-
Gedung-gedung
(d+e)
Rp.
VI
Rp.
Rp.
Jumlah (a)
Rp.
Aktiva Lain (c)
Rp.
Jumlah
Rp.
III
Jumlah
Rp.
*)
Piutang jangka pendek (sampai dengan enam bulan) : Rp. ………………
Piutang jangka panjang (lebih dari enam bulan)
: Rp. ………………
_______________
Jumlah
: Rp. ………………
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16. VENDOR’S BANK INFORMATION FOR WIRE TRANSFERS
BENEFICIARY INFORMATION
Vendor Name
Vendor Number
Address (Street/City/State/Zip/Country)
Phone Number
Tax Identification Number
BENEFICIARY BANK INFORMATION
Beneficiary Bank Name
Address (Street/City/State/Zip/Country)
Beneficiary Routing Information (SWIFT, Sort code, BSB, etc)
Beneficiary Account Number
Name of Bank Account
Currency
Special Insttructions
INTERMEDIARY BANK INFORMATION
Intermediary Bank Name
Intermediary Routing Information
(SWIFT, Sort code, BSB, etc)
Intermediary Bank Address (Street/City/State/Zip/Country)
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The undersigned verifies the accuracy of the information submitted and authorizes PTJM to obtain
information from Supplier’s references, including financial and banking. The undersigned also
understands that this is simply part of a registration prodess with PTJM and does not imply any
intent on the part of PTJM.
Company:
______________________________________________________
Materai
Rp6000;
Tanggal dan
Cap
Perusahaan
Authorized Signature
By:
Name:
______________________________________________________
Title:
______________________________________________________
Date:
______________________________________________________
For PTJM Internal Use Only:
Approved
Not Approved
Approved by
Date
Comments:
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