SAKA INDONESIA PANGKAH LIMITED

PRE-QUALIFICATION
DOCUMENT

FOR

PROVISION OF INTEGRATED MANPOWER SERVICES

FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

REFERENCE
BID 17-0038
BID 17-0038 PROVISION OF INTEGRATED MANPOWER SERVICES
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

PREQUALIFICATION DOCUMENT

FOR

PROVISION OF INTEGRATED MANPOWER SERVICES

FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

TABLE OF CONTENTS

A. Invitation For Prequalification

B. General Qualification

C. Instruction To Applicant ( ITA )

D. List of Exhibit For Prequalification Form

Exhibit 1 - Form of Letter of Application

Exhibit 2 - Form of Prequalification Questionnaire

Exhibit 3 - Form of Statement Letter For Authenticity Document

Exhibit 4 - Form of Applicant Business & Legal Status

Exhibit 5 - Form of Statement Letter of Applicant Contractual Performance

Exhibit 6 - Form of Statement Letter for Domestic Company Status

Exhibit 7 - Form of Statement Letter for Local Content Compliance

Exhibit 8 - Form of Statement Letter for Pakta Integritas & Kepatuhan UU Tipikor

Exhibit 9 - Form of Statement Letter for Employing Bank With BUMN/BUMD Status

Exhibit 10 - Form of Statement Letter For Basic Ability

Exhibit 11 - Consortium Definition & Clause

E. Scoring/Passing Grade system

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BID 17-0038 PART A
PROVISION OF INTEGRATED MANPOWER SERVICES INVITATION FOR PREQUALIFICATION
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

PART A

INVITATION FOR PREQUALIFICATION

Dear Sirs,

Following Tender Announcement, Saka Indonesia Pangkah Limited ( referred to as COMPANY ) hereby
invites your Company to participate in Pre-Qualification Process for the referenced work. The requirements
for registration are detailed in this document.

Please note that all communications relating to this Pre-Qualification Process shall be made in writing and
addressed to as follows :

Saka Indonesia Pangkah Limited

The Energy, 11th 12th Floor, SCBD Lot 11A
Jl. Jend. Sudirman Kav. 52-53, Jakarta 12190
Attn. : Procurement Committee
Email : 1) Procurement.Committee.Jakarta@sakaenergi.com
2) istondo.prayudi@sakaenergi.com
3) mirza.riandyani@sakaenergi.com
4) eko.wahyudi@sakaenergi.com

Phone : +62 31 293 1300

Fax : +62 31 393 0216

Ref. Bid :
BID 17-0038 ; Provision Of Integrated Manpower Services
For Onshore & Offshore Facilities of Ujung Pangkah

We hereby look forward to your participation.

Regards,

Ridha M. Saad
Bid Committee Chairman

SAKA Indonesia Pangkah Limited is committed to embrace the highest business ethics. We shall appreciate and seriously follow up
any concern on any alleged ethical issues surrounding our business process (including but not limited to our procurement process). If
you have any concern or inputs to Saka business process, please feel free to relay such concerns/inputs to ethic@sakaenergi.com.

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

PART B
GENERAL QUALIFICATIONS

1. GENERAL

Saka Indonesia Pangkah Limited as the Operator for the Pangkah Offshore PSC located at Pangkah
Offshore Field, Gresik - East Java, Indonesia (hereinafter referred to as COMPANY) intends to pre-
qualify Contractors for the Provision of Integrated Manpower Services For Onshore & Offshore
Facilities of Ujung Pangkah ( Bid 17-0038 ) hereinafter referred to as The WORK to support
Pangkah Operations.

2. TENDER PROCESS AND DATE

It is anticipated that bidding and execution of the contract will be as follow:

1. Pre-qualification Registration : 27 February 02 March 2017

2. Pre-qualification Doc. Distribution : 07 08 March 2017
3. Prequalification Submission : 21 February 2017 by 14:00 OClock
4. Issue ITB (invitation to Bid) : April 2017 ( Estimated )
5. Bid Submission : April 2017 ( Estimated )
6. Contract Award : June 2017 ( Estimated )

3. PROJECT BACKGROUND

Saka Indonesia Pangkah Limited ( hereinafter referred to as COMPANY ) is an Exploration and

Production COMPANY in Indonesia that developes and maintains Ujung Pangkah, East Java
Operation Area. The Ujung Pangkah field is located offshore, 50 Km North West of the city of
Surabaya in a water depth of +/- 10m. Facilities are currently under production bringing both
natural gas and crude oil via a 40 km pipeline to an onshore processing plant located at Gresik,
within the Maspion Industrial estate. The facilities have been in production since April 2007. The
crude oil/condensate delivered to the export point via a 24 pipeline which runs the length of the 2
km long Maspion jetty and loaded onto vessels using 2 x 12 inch MLA. The natural gas will be sold
to PLN at the Gresik power station about 7 km to the south.

Produced water, Oil and gas from WHP-A (offshore area) are exported to Onshore Processing Facility,
OPF via 18 pipeline. Pig launcher, 203-MQ-01 is installed on WHP-A for facilitating pigging
operation for pipeline cleaning, chemical treatment, pipeline inspection and removing slugs or debris
in the pipeline. Pig receiver, 131-NQ-01 is installed on OPF in Manyar, Gresik.

At first quarter 2010, additional 12 and 16 Pipeline facilities connecting WHP-A to new platform
WHP-B (Offshore) accomplish. 12 pipeline will be as liquid transporter (3 phase) from WHP-A to
WHP-B along 5.5 Km, and 16 pipeline will be as gas transporter from WHP B - to WHP-A along 5.5
Km.

To ensure that Operations Facility and System will work as well as the plan, some of skillful
manpower meet the specufic competency are reqired. Its therefore COMPANY foresees the needs for
the Provision of Integrated Manpower Services For Onshore & Offshore Facilities of Ujung
Pangkah.

Securing the needs, COMPANY intends to develop 3 (three) years contract period through from a
competetive tender which started from this Prequalification Phase.

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

4. SUMMARY OF THE WORKS

4.1. Requirement Background

1. Integrated Manpower Services

COMPANY have two (2) Core Facilities where the production and operation of Oil and Gas
are organized. All this time, manpower support are sourced and managed independently
based on Departmental Policy wherein Offshore Manpowers are lean on Offshore
Department, while Onshore Manpowers are under Onshore Policy.

Considering the circumstances where effectiveness and synergy are diffult to reach,
COMPANY decided to improve the manpower strategy through one (1) integrated
manpower contract which will be managed under Human Resources Function as
COMPANYs Change Agent in term of any employ and employment.

2. Contract Management Improvement

Through an integrated manpower contract, at least COMPANY had set to gain the
following Contract Management effectiveness ;
a. Managing Relationship
Integrated Contract may deliver an easiness for COMPANY and CONTRACTOR in
developing effective communication, value and culture alignment, and problem
mitigation when its occur during CONTRACT period.
b. Service Delivery
Integrated Contract may deliver an easiness for COMPANY and CONTRACTOR to
measure service level, quality, value for money, and risk.
c. Contract Administration
Integrated Contract may deliver an easiness for COMPANY in managing any
CONTRACT elements ( administration, scope of works, commercial, legal ) and
accuracy during CONTRACT commencement.

3. Ongoing Contract

At the moment two (2) Manpower Provider are work with COMPANY with a different
Contracts for Onshore and Offshore Facility.

Based upon the above circumstances, COMPANY perceives the needs for the Provision of
Integrated Manpower Services For Onshore & Offshore Facilities of Ujung Pangkah.

4.2. The WORKS

All the things described below, hereinafter referred to as the WORK.

Mainly the WORKS are divided into the following Group ;

1. Human Resources Management System
CONTRACTOR is required to provide competent and qualified Human Resources
Management System in managing human resources and/or outsourcing business which
including but not limited to the following ;
a. Smart Recruitment, Selection, and Hiring System
Despite any business uncertainty and handicaps, CONTRACTOR shall have a smart
recruitment, selection, and hiring system to keep getting qualified personnel meet
requirement in the pool of job seekers and or personnel market place.
Including in this strategy is/are CONTRACTOR expertise and maturity in reviewing
COMPANYs Job Descriptions or Qualification Credential, selecting and hiring any
applicants which technically perceives as fit to work.
b. Orient A New Employee System
CONTRACTOR shall have an Orientation Program to where any new employee will be
oriented to cultivate both CONTRACTORs and COMPANYs Value.

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

During personnel assignment, CONTRACTOR shall be responsible to elaborate

CONTRACTORs Value as personnel employer and COMPANY as the organization
where any personnel is assgined to deliver the services.
Including in this clause is that CONTRACTOR responsibility to educate the new
employee for role and responsiblity, the expected result of the job they are hired, and
set of compensation and benefit they will be rewarded.

c. Placement System
CONTRACTOR shall have set of management standard and policy that clearly guide
any employee and personnel for his/her responsibility goals and how it will be
measured to ensure that the right person in the right place is achieved.

d. Compensation and Benefit Management System

CONTRACTOR shall be responsible to provide payroll management system at the best
class wherein pay the personnel in full, in compliance with any regulation, and timely
manner are the main objective.

e. Supervision
To keep motivate the assigned personnel in delivering the optimum performance,
CONTRACTOR shall be responsible to provide personnel supervision system, and
evaluation management system to reward performance achievement.

f. Evaluation Administration & Reporting System

CONTRACTOR shall have an administration and reporting management system that
deal with any personnel employment and CONTRACTOR responsibility as an
organization to COMPANY and or Government as a regulatory body.

2. Manpower Supply

CONTRACTOR shall provide manpower meet the follwing Manpower List ;

a. Onshore Regular Manpower
Working
# Position Headcount
Schedule
1 ASSISTANT - PLANNER 1 NORMAL
2 ASSISTANT - INSTRUMENT TECHNICIAN 1 NORMAL
3 ASSISTANT - ELECTRICAL TECHNICIAN 1 NORMAL
4 ASSISTANT - ENGINEERING TECHNICIAN 1 1 NORMAL
5 ASSISTANT - ENGINEERING TECHNICIAN 2 1 NORMAL
6 ASSISTANT - MATERIAL MANAGEMENT 1 NORMAL
7 ADMIN - MATERIAL MANAGEMENT 1 NORMAL
8 HELPER - INSTRUMENT 1 NORMAL
9 HELPER - ELECTRICAL 1 NORMAL
10 HELPER - MECHANICAL 5 NORMAL
11 HELPER - INSTRUMENT (SHIFT) 3 SHIFT
12 HELPER - ELECTRICAL (SHIFT) 3 SHIFT
13 HELPER - MECHANICAL (SHIFT) 3 SHIFT
14 HELPER - PAINTING 2 NORMAL
15 HELPER - PRODUCTION OPERATOR 4 NORMAL
16 CONSTRUCTION OPERATOR 2 NORMAL
TOTAL HEADCOUNT 31

Working Schedule shall be defined as number of days and times when manpower is
expected or rquired to be working that is distinguished into the following two (2)
groups ;
a. Normal Working Schedule : 5 days a week, Monday Friday, 9 Hours/Day incl.
Of 1 Hour Lunch Break.

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

b. Shift Working Schedule : 5 Days ON 5 Days Off, 12 Hours / Day incl. Of 1

Hour Lunch Break.

b. Onshore On Call Manpower

# POSITION HEADCOUNT

1 HELPER - MAINTENANCE HEADCOUNT & DETAIL

2 WELDER & FITTER REQUIREMENT TO BE ADVISED
3 PROJECT CONTROL DURING TENDER PHASE

c. Offshore Regular Manpower

WORKING
# POSITION HEADCOUNT
SCHEDULE
1 ASSISTANT - TECHNICIAN ELECTRICAL 2 SHIFT
2 ASSISTANT - TEHNICIAN INSTRUMENT 2 SHIFT
3 ASSISTANT - TEHNICIAN MECHANICAL 2 SHIFT
4 ASSISTANT - PRODUCTION OPERATOR 10 SHIFT
5 OFFSHORE TECHNICAL ASSISTANT 2 SHIFT
6 CRANE OPERATOR 2 SHIFT

TOTAL HEADCOUNT 20

Working Schedule shall be defined as number of days and times when manpower is
expected or rquired to be working that is decided under one (1) single group ;

- Shift Working Schedule ; 2 Weeks ON 2 Weeks Off, 12 Hours/Day incl. Of 1

hour Lunch Break.

d. Offshore On Call Manpower

# POSITION HEADCOUNT

1 TECHNICIAN - HEALTH, SAFETY, ENV. HEADCOUNT & DETAIL

2 HELPER - PRODUCTION & MAINTENANCE REQUIREMENT TO BE ADVISED
3 WELDER AND FITTER DURING TENDER PHASE

4.3. OTHER SCOPE OF WORKS

Other Scope of WORKS which might comprise of but not limited to the following aspect to be
further described in tender document during tender process ;
Manpower Qualification
Manpower Role and Responsibilities
Manpower Compensation & Benefit Standard
Personnel Protective Equipment
Contractor Representative Office
Remuneration Package
Employment
Working Hours
Transportation, Meal & Accommodation
BPJS
Hospital, Medical Check Up, and Insurance
Daily Administration
Working Area
Permit To Work System
Contract Coordination
Work Order Mechanism ( for On Call Manpower )
Report & Documentation
Contractor Responsibilities
Company Responsibilities

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

5. REQUIREMENT FOR PREQUALIFICATION

This prequalification is only open to Indonesian companies. The information provided by the
Applicant in response to this document as requested in Part B will be used to assess the capability
of the Applicant to perform the work. Assessment of capability may (if required by COMPANY) also
include a presentation by the Applicant at the invitation by COMPANY and/or a visit to the
Applicants office to verify the information provided. The determination will take into account the
Applicants financial, technical capabilities, experience and past performance based upon an
examination of the documentary evidence submitted by the Applicant
To be qualified, the Applicant must meet all of the following requirements:
1. ADMINISTRATION

1.1. LETTER OF APPLICATION

Applicant shall submit the Application Letter that meet with the following criteria:
a. Is on Applicants letter head, dated, endorsed with applicant corporate stamp/seal.
b. Is signed by authorized signatory person pursuant to the deed of establishment/
amendment or by Representative of Goods/Services Provider
Form of Letter of Applicant provided in Exhibit - 1

1.2. FORM OF PRE-QUALIFICATION QUESTIONNAIRE

Applicant shall submit a complete information as required in Form of Pre-Qualification

Questionnaire.

From of Pre-Qualification shall be in Applicants letter head, dated, duty stamped,

endorsed by applicants corporate stamp/seal, and signed by authorized signatory
person pursuant to the deed of establishment/ amendment or by Representative of
Goods/Services Provider
Form of Pre-Qualification Questionnire provided in Exhibit - 2

1.3. PERMIT AND LICENSE

Applicant shall submit the following documents:

a. Copy of Akte Notaris (Article of Incorporation) and its Amendment (if any).
b. Copy of Companys Domicile Letter approved by the authorized institution.
c. The list of its Shareholders and Board of Directors & Management.
d. Appointment Letter as Indonesian Sole Agent issued by Manufacture applicable for
Applicant who acts as a Sole Agent for any materials or services related to the WORK
e. Copy of valid Tax Payer Identification Number (NPWP) and PKP.
f. Copy of Tax Payment Receipt for the latest 3 months for PPh 25, PPh 21 or PPh 23
and PPN.
g. Copy of ASTEK/JAMSOSTEK.

1.4. SET OF STATEMENT LETTER FROM APPLICANT

a. Statement Letter For Autenthicity Document

Applicant shall submit statement letter which stating the Authenticity of the
provided documents
Form of Statement Letter For Auttenthicity Docuemnt provided in Exhibit - 3

b. Statement Letter For Applicant Business & Legal Status

Applicant shall submit statement letter which stating that Applicant is not under
court surveillance, bankruptcy proceedings or investigations, its business in not
under any legal restriction or awaiting a decision of court.
Form of Statement Letter For Applicant Business & Legal Status provided in Exhibit - 4

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

c. Statement Letter For Applicant Contractual Performance

Applicant shall submit statement letter which stating that Applicant is not under
Red Sanction of Saka Indonesia Pangkah Limited, and/or under Black Sanction of
other Company within Oil & Gas Industry in Indonesia.
Form of Statement Letter For Applicant Contractual Performance provided in Exhibit - 5

d. Statement Letter Of Domestic Company Status

A Large Sclale Applicant ( Perusahaan Golongan Usaha Besar ) thats declaring and
registering in this tender as a Domestic Company ( Perusahaan Dalam Negeri ) or
BUMN Afiliated shall submit Statement Letter of Domestic Company which
supporting with the following document ;
a. Copy of Legalized Akte Notaris (Article of Incorporation).
b. Statement Letter for truthfullnes information endorsed by Legal Consultant

Form of Statement Letter Domestic Company Status provided in Exhibit - 6

Both Copy of Legalized Akte Notaris and Statement Letter shall cover the following
Domestic Companys Characteristic ;

a. The Company incorporated under the laws of the Republic Indonesia owned by
Indonesian Citizen (WNI), District Government (Pemerintah Daerah), State-
Owned Company (BUMN) and/or District-Owned Company (BUMD) with 51%
of shares has a voting right, dividend rights and Management Control Rights.
b. The Company incorporated under the laws of the Republic Indonesia wherein
2/3 (two-third) of number of directors, including of the Board of Directors that
is accountable for financial and strategic management, is a citizen of Indonesia
(WNI)

Higlight for Applicant Consideration ;

Definition of Domestic Company ;
(Perusahaan Dalam Negeri adalah perusahaan yang didirikan berdasarkan
hukum negara Republik Indonesia dan minimal 51% (lima puluh satu persen)
dari saham yang memiliki hak suara (voting right), hak dividen dan hak Kendali
Manajemen dimiliki oleh perseorangan Warga Negara Indonesia (WNI), BUMN/D,
pemerintah daerah dan/atau negara Republik Indonesia serta minimal 2/3 (dua
per tiga) anggota direksi, termasuk pimpinan tertinggi perusahaan dan anggota
direksi yang bertanggungjawab atas pengelolaan keuangan dan strategi bisnis,
adalah WNI).

In the event that Appicant fails to submit Statement of Domestic Company

status meet requirement COMPANY may consider Applicant as Non Domestic
Company wherein No Local Content Preference will be granted into any
commercial aspect in the tender.
COMPANY source of Domestic Company reference check will be APDN BOOK
endorsed by Direktorat Jenderal Minyak Dan Gas Bumi.

e. Statement Letter For Local Content Compliance

Applicant shall submit statement letter which stating the commitment to achieve
Local Content ( Tingkat Kandungan Dalam Negeri ) at the minimum of 35% against
total Contract. Actual achievement of Local Content will be assessed by COMPANY
upon Contract Expiration to identify Applicants commitment consistency.
Form of Statement Letter Of Local Content Compliance provided in Exhibit 7

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

f. Statement Letter For Pakta Integritas dan Kepatuhan Terhadap UU Tipikor

Applicant shall submit Statement Letter which stating willingness and good faith to
be audited from the compliance perspective against Undang-Undang Tindak Pidana
Korupsi, FCPA dan/atau ABC performed by Independen Auditor that is appointed by
COMPANY and/or SKKMIGAS.
Form of Statement Letter of Pakta Integritas & Kepatuhan UU Tipikor provided in Exhibit - 8

g. Statement Letter Of Employing Bank With BUMN/BUMD Status

Applicant shall submit statement letter which stating that Applicant posses bank
account in a Bank with BUMN/BUMD Status which will be used solely for any
payment of transaction.
Form of Statement Letter Of Employing Bank With BUMN/BUMD Status provided in Exhibit 9

h. Statemen Letter Of Basic Ability

Applicant shall submit statement letter completed with the calculation stating the
Basic Capability ( Kemampuan Dasar = KD ) to qualify Applicant Financial
Capability.
Basic Capability shall meet the following characteristic ;
a. Basic Capability shall be consistent with Experience Document as stated on 5.
Requirement For Prequalification, 3. Experience.
b. Basic Capability shall be supported with the copy of PO or Contract.
c. Basic Capability shall be determined based on Nilai Pengalaman Tertinggi
(NPT)
Form of Statement Letter Of Basic Ability provided in Exhibit - 10

All Statement Letters shall be in Applicants letter head, dated, duty stamped, endorsed
by Applicants corporate stamp/seal, and signed by authorized signatory person pursuant
to the deed of establishment/ amendment or by Representative of Applicant.

1.5. ORGANIZATION STRUCTURE

Applicant shall submit Organizational Structure complete with Detail Description on each
Role & Responsibility of key Person.

1.6. CONSORTIUM CLAUSE

To Applicant intends to participate in Pre-Qualification as a Consortium Company shall ;

a. Submit the required Consortium Document i.e. Consortium Agreement /
Memorandum of Understanding with reference to Exhibit 10, Consortium Definition
& Clause, 2. Syarat Konsorsium.

b. Administer the Consortium practice completely to be in reference to Exhibit 10,

Consortium Definition & Clause, 2. Syarat Konsorsium.

c. Consortium Companies ( All Companies bind its agreement in Consortium ) shall

submit a complete documents as required in this Pre-Qualification Requirement.
Consortium Definition & Clause provided in Exhibit - 11

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

2. TECHNICAL

2.1. VALID BUSINESS PERMIT & LICENSE

Applicant to submit valid Business Permit & License and/or Certificate endorsed by the
authorized institution and showing the qualification meet to the WORK ;
a. Surat Ijin Operasional Perusahaan Penyedia Jasa Pekerja ( SIO PPJP )
endorsed by Government Institution who has relevant certifying authority
(Kementrian Tenaga Kerja Dan Transmigrasi pada Instansi yang
bertanggungjawab di Tingkat Propinsi).
b. Sample of Surat Bukti Pendaftaran Kontrak Tenaga Kerja for the past
CONTRACT held by Applicants within the the previous 7 (seven) year.

2.2. SAMPLE OF STRATEGY FOR COMPENSATION & BENEFIT MANAGEMENT SYSTEM

To ensure that Applicant can provide adequate qualification to perform the WORK,
Applicant shall submit the sample of strategy on how below sample of compensation and
benefit will be managed ;

COMPENSATION & BENEFIT APPLICANT

#
COMPONENT TO DESCRIBE COMPLETELY
1 BPJS Tenaga Kerja ( JHT, JKM, JKK )
Applicant to describe the strategy to manage this
2 BPJS Pensiun
C&B Component ( expertise based is allowed )
3 BPJS Kesehatan
4 Vacation Allowance Bidder to describe the strategy to manage this C&B
5 Tunjangan Hari Keagamaan Component ( expertise based is allowed )
6 Severance Payment
Note :
Applicant to provide Exececutive Summary which might be supported with sample of Standard Operation
Procedure, and Policy

3. EXPERIENCE
3.1. Experience Within The Last 7 (seven) Years
Applicant shall have experience in similar WORK within the last seven (7) years.
Applicant shall submit list of experiences which are meet / consist of the following
information :
Company, Phone and Facsimile No., Contact Person.
Title of the works
Works Duration
Contract Amount
Copy of Purchase / Service Order
List of experience shall be presented meet the data as shown in PQ QUESTIONNAIRE
FORM.
Form of Pre-Qualification provided in Exhibit - 2
Experiences which are not meet with the pre-qualification / tender subject or title wouldnt
be considered on evaluation or decided as not entitled for scoring.

3.2. Successful Contract Performance

CONTRACTOR shall submit at the maximum 2 (two) samples of historical Contract
Performance met to the WORKS which accomplished in success or satisfied result. In
order to simplify Applicant Qualification assessment, information related to Successful
Contract Performance shall described as follow ;

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

NO. CONTRACT DATA CONTRACT - 1 CONTRACT - 2

1 CONTRACT NO.
2 CONTRACT TITLE
3 CONTRACT PERIOD
A. START DATE
B. END DATE
4 CONTRACT VALUE
5 COMPANY
6 PHONE/FACSIMILE
7 CONTACT PERSON
8 CONTRACT PERFORMANCE
SUCCESSFUL KEY POINT
A. QUALITY OF WORKMANSHIP
B. TIME MANAGEMENT
C. PROJECT MANAGEMENT
D. HEALTH & SAFETY
E. TECHNOLOGY & METHOD

Successful or satisfied result of contract performance shall be defined as Execution of a

contract by which the contracting parties are automatically discharged (see discharge of
contract) of their obligations under it which consist of the following samples successful
key point ;
Quality of Workmanship
Time Management
Project Management
Contract Management
Health and Safety
Technology and Method

4. HEALTH SAFETY AND ENVIRONMENT

Not Applicable.

5. FINANCIAL

5.1. BANK REFERENCE

The Applicant shall submit original letter from Bank as evidence.
5.2. BANK ACCOUNTS
Applicant must have bank account in one of the BUMN / National Bank. Please state
your account number. If Applicant does not have the bank account in one of the BUMN
/ National Bank the bid proposal will be disqualified.

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

PART C
INSTRUCTIONS TO APPLICANTS

1. SCOPE OF BID 1.1 Saka Indonesia Pangkah Limited, as the Operator for the Pangkah Offshore
PSC located at Pangkah Offshore field, East Java, Indonesia (hereinafter
referred to as COMPANY) intends to pre-qualify Contractors (firms) for BID
17-0012 PROVISION OF 20 SALES GAS PIPELINE ONLINE REPAIR SERVICES
(hereinafter referred to as WORK).

2. PREQUALIFICATION 2.1 The document for the prequalification of Applicants (hereinafter

DOCUMENT prequalification document) comprise all the sections indicated below, and
should be read in conjunction with any Addendum issued in accordance with
ITA 3.

Part A Invitation to Prequalification

Part B General Qualification
Part C Instructions to Applicants
Part D Prequalification Form
2.2 The COMPANY accepts no responsibility for the completeness of the
prequalification document and its addenda unless they were obtained
directly from the COMPANY.
2.3 The Applicant is expected to examine all instructions, forms, and terms in the
Prequalification Document and to furnish all information or documentation
required by the Prequalification Document. Failure to provide information that
is essential to evaluate the Applicants qualifications, or to provide timely
clarification or substantiation of the information supplied, may result in
disqualification of the Applicant.

3. AMENDMENT OF 3.1 At any time prior to the deadline for submission of applications, the
PREQUALIFICATI COMPANY may amend the Prequalification Document by issuing addenda.
ON DOCUMENT
3.2 Any addendum issued shall be part of the Prequalification Document and
shall be communicated in writing to all who have obtained the
prequalification document from the COMPANY.

3.3 To give prospective Applicants reasonable time to take an addendum into

account in preparing their applications, the COMPANY may, at its
discretion, extend the deadline for the submission of applications.

4. COST OF 4.1 The Applicant shall bear all costs associated with the preparation and
APPLICATION submission of its application, including any costs incurred in the process of
discussions, clarifications, meetings and the preparation of the
prequalification submission. The COMPANY will in no case be responsible
or liable for those costs, regardless of the conduct or outcome of the
prequalification process.

5. SUBMISSION OF 5.1 Submissions of Applications for Prequalification must be received in sealed

APPLICATIONS envelope ( 1 (one) original and 1 (one) copy ) and delivered to the following
arrangement :
a. Prequalification Document Date of Submission
Applicant shall submit Prequalification Document not later than ;
21 February 2017 14.00 OClock
b. Place of Prequalification Document Submission
SAKA INDONESIA PANGKAH LIMITED
Onshore Processing Facilities
Kawasan Industri Maspion
Jl. Beta Raya Manyar KM 25
Desa Manyar Sukomulyo, Kecamatan Manyar
Gresik 61151, East Java
Attn. : Supply Chain Management

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BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

c. Marking or Labelling of Prequalification Envelope

Applicant shall ensure that the following marking or labelling is put on

Prequalification Envelopes ;
BID 16-0208R
APPLICATION PREQUALIFICATION DOCUMENT
PROVISION OF INTEGRATED MANPOWER SERVICES FOR
ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH
Attn. BID COMMITTEE / SUPPLY CHAIN MANAGEMENT

d. Prequalification Submission Method

COMPANY considers two (2) method of Prequalification Document ;
1. Hand Carry
Applicant shall submit prequalification document by hand carry
directly to the Place as stated on Part C, INSTRUCTION TO
APPLICANTS, 5. SUBMISSION OF APPLICANTS, b. Place of
Prequalification Document Submission as stated in document.
2. Courier Services
In the event that Prequalification Submission Method through a
Hand Carry is not applicable for Applicant, Applicant may consider
to submit it through a Courier Services.

Applicant shall consider the following terms carefully when

Prequalification Document Submission by Courier Services is
chosen ;
a. Applicant shall ensure that the following delivery risk is
prevented as its fully Applicant responsibility.
Prequalification Document is late received by COMPANY
later than Prequalification Document Date of Submission.
Prequalification Document is not received by COMPANY.
Prequalification Document is not meet the required
document quality and/or damage during delivery

b. Applicant shall fully responsible to expedite Prequalification

Document for the purpose of anticipating courier service lead
time and selecting reputable courier services which have an
express delivery services to reach Prequalification Document
Date of Submission.

c. No exception
No Exception will be given to Applicants who submit
Prequalification Document through a Courier Services. Any
terms and conditions, clause, requirement as stated in any
pages of this Prequalification Document For Provision of
Integrated Manpower Services For Onshore & Offshore
Facilities of Ujung Pangkah, Reference Bid 17-00387 will
remain effect.

The COMPANY reserves the right to accept or reject late applications.

5.2 Electronic and hard copies will be exactly the same as the text of the
original prequalification submittal. In the event of discrepancies, the
original paper prequalification submittal will have precedence.
Copies will not necessarily be checked for accuracy by COMPANY, but will
be assumed to be faithful reproductions of the original paper
prequalification submittal.
5.3 The name and mailing address of the Applicant will be clearly marked on
the envelope.

Page 14 of 31
BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

5.4 All the information requested for prequalification will be answered in the
English language. Where information is provided in another language, this
will be accompanied by a translation of its pertinent parts into English.
This translation will govern and be used for interpreting the information.

6. CONFIDENTIALITY 6.1 The information contained within this prequalification document shall be
regarded as confidential and shall not be divulged to any third party
without the written consent of Company. Correspondingly, all
prequalification submissions received, will be treated as confidential by
Company-except as required by Indonesian regulation.

7. CLARIFICATION 7.1 To assist in the evaluation of applications, the COMPANY may, at its
OF APPLICATION discretion, ask any Applicant for a clarification of its application which shall
be submitted within a stated reasonable period of time. Any request for
clarification and all clarifications shall be in writing.

7.2 If an Applicant does not provide clarifications of the information requested

by the date and time set in the COMPANYs request for clarification, its
application may be rejected.

8. EVALUATION OF 8.1 The COMPANY shall use the factors, methods, criteria, and requirements
APPLICATION defined in Part B, General Qualification to evaluate the qualifications of the
Applicants. The COMPANY reserves the right to waive minor deviations in
the qualification criteria if they do not materially affect the capability of an
Applicant to perform the contract.

8.2 The pre-qualification evaluation will adopt below method :

a. Scoring System

KILLING
EVALUATION ASPECT MAX. SCORE
POINT
ADMINISTRATION ASPECT 40 0
ADMINISTRATION ASPECT - SCORING 40 0
TEHNICAL ASPECT
1 VALID SIO PPJP - KEMENAKERTRANS TINGKAT PROPINSI 20 20
2 SURAT BUKTI PENDAFTARAN KONTRAK TENAKER 10 10
3 SAMPLE OF STRATEGY FOR COMPENSATION & BENEFIT 30 21
MANAGEMENT SYSTEM
TECHNICAL ASPECT - SCORING ( KP = 70% ITEM #3) 60 51
EXPERIENCE ASPECT
1 LIST OF EXPERIENCES 30 21
2 SAMPLE OF SUCCESSFUL CONTRACT PERFORMANCE 20 14
EXPERIENCE ASPECT - SCORING ( KP = 70% OF ITEM 1 & 2 ) 50 35
FINANCIAL ASPECT
1 BANK REFERENCE 5 0
2 BANK ACCOUNT 5 5
FINANCIAL ASPECT - SCORING ( KP = 5, ITEM #2 ) 10 5
TOTAL SCORE 160 91

b. Passing Grade :

NO CRITERIA SCORE
1 MINIMUM PASSING GRADE FOR OVERALL SCORE 119
2 KILLING POINT EACH
A. EACH EVALUATION ASPECT ALLOCATED
TECHNICAL ; 51, EXPERIENCE ; 35, FINANCIAL ; 5 SCORE
B. TOTAL KILLING POINT SCORE 91

Evaluation Criteria :
Fail to meet the minimum passing grade subject to disqualification.
Failure to meet the score and or submit one or more supplement
captured in Killing Point subject to disqualification.

Page 15 of 31
BID 17-0038 PART C
PROVISION OF INTEGRATED MANPOWER SERVICES INSTRUCTION TO APPLICANT
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

c. Basic Ability ( Kemampuan Dasar )

Basic Ability Criteria ;

KD = 5 NPt

Based on the WORK characteristic, coeficient to decided KD was

decided at 5 NPt.

KD minimum : IDR. 10,844,326,494

KD minimum shall be defined as minimum Basic Ability that
Applicant shall reach based on Applicant Highest Experience.

d. Remaining Project Ability :

Not Appplicated in this tender.

Fail to meet the criteria on Basic Ability and Remaining Project Ability
subject to not evaluated on further tender selection.

8.3 Once the COMPANY has completed the evaluation of the applications it
shall notify all Applicants in writing of the names of those applicants who
have been pre-qualified without assigning any reason for the COMPANYs
decision.

9. COMPANYS 9.1 The COMPANY reserves the right to :

RIGHT TO (i) amend the scope and value of any contract(s) to be bid, in which
event the contract(s) will be bid only among those prequalified
bidders that meet the requirements of the contract(s) as amended;
(ii) reject or accept any application; and
(iii) cancel the prequalification process and reject all applications.

The COMPANY will neither be liable for any such actions nor be under any
obligation to inform the Applicant of the grounds for them.

10. INVITATION TO 10.1 Promptly after the notification of the results of the prequalification the
BID COMPANY shall invite bids from all the Applicants that have been pre-
qualified.

10.2 Bidders may be required to provide a Bid Security or a Bid Securing

Declaration acceptable to the COMPANY in the form and an amount to be
specified in the Bidding Documents, and the successful Bidder shall be
required to provide a Performance Security to be specified in the Bidding
Documents.

Page 16 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR PREQUALIFICATION FORM
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

PART D
LIST OF EXHIBIT FOR PREQUALIFICATION FORM

The prequalification forms are provided in to the following Exhibit ;

Exhibit 1 - Form of Letter of Application

Exhibit 2 - Form of Prequalification Questionnaire
Exhibit 3 - Form of Statement Letter For Authenticity Document

Exhibit 4 - Form of Applicant Business & Legal Status

Exhibit 5 - Form of Statement Letter of Applicant Contractual Performance

Exhibit 6 - Form of Statement Letter for Domestic Company Status

Exhibit 7 - Form of Statement Letter for Local Content Compliance

Exhibit 8 - Form of Statement Letter for Pakta Integritas & Kepatuhan UU Tipikor

Exhibit 9 - Form of Statement Letter for Employing Bank With BUMN/BUMD Status

Exhibit 10 - Form of Statement Letter For Basic Ability

Exhibit 11 - Consortium Definition & Clause

Notes :

1. If necessary, additional sheets may be added to the form. Each page of each forms should be
clearly marked in the right top corner as follows : Form I, Page 1 ; Form I, Page 2, etc. if the form
goes beyond one page.

2. Some of the forms will require attachments. Such attachments should be clearly marked as follows:
Attachment 1 to Form I, Attachment 2 to Form I, etc.

Page 17 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

EXHIBIT 1
LETTER OF APPLICATION

[letterhead of the Applicant, or partner responsible

for a joint venture, including full postal address,
telephone no., facsimile no., telex no., and cable
address]

Date : _____________________

To: SAKA INDONESIA PANGKAH LIMITED

The Energy, 11th Floor
SCBD Lot 11A
JL. Jend. Sudirman Kav. 52-53
Jakarta, 12190

Sirs,

1. Being duly authorized to represent and act on behalf of ____[name of the Applicant]__________,
hereinafter the Applicant, and having reviewed and fully understood all the prequalification
Documents provided, the undersigned hereby applies to be prequalified by yourselves as a bidder for
the following:

Ref No : Bid Title :

BID-..

2. The COMPANY and its authorized representatives are hereby authorized to conduct any inquiries or
investigations to verify the statements, documents, information submitted in connection with this
application, and to seek clarification from our bankers and clients regarding any financial and
technical aspects. This Letter of Application will also serve as authorization to any individual or
authorized representative of any institution referred to in the supporting information, to provide such
information deemed necessary and requested by yourselves to verify statements and information
provided in this application, or with regard to the resources, experience, and competence of the
Applicant
3. The COMPANY and its authorized representatives may contact the following persons for further
information :
Contact 1
Name : Telephone :
Position : Fax :
E-mail :
Contact 2
Name : Telephone :
Position : Fax :
E-mail :

4. This application is made in the full understanding that :

(i) bids by prequalified Applicants will be subject to verification of all information submitted for
prequalification at the time of bidding;

(ii) The COMPANY reserves the right to:

amend the scope and value of any contracts bid under this project; in such event, bids will
be called only from prequalified bidders that meet the revised requirements; and
reject or accept any application, cancel the prequalification process, and reject all
applications.

(iii) The COMPANY will not be liable for any such actions and will be under no obligation to inform
the Applicant of the grounds for them.

Page 18 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

5. The undersigned declare that the statements made and the information provided in the duly
completed application are complete, true, and correct in every detail.

Signed

Name :

For and on behalf of ...

Page 19 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

EXHIBIT 2
PREQUALIFICATION QUESTIONNAIRE

Provided in a separate document.

EXHIBIT 3
STATEMENT OF AUTHENTICITY OF DOCUMENT

On this _______day of __________ 2017 the undersigned:

Name :
Position :
Company :
Company Address :

in this matter acting in my above mentioned capacity and therefore for and on behalf of the above
mentioned company hereby acknowledges, declares and warrants that for the purpose of participating in
subject tender held by Saka Indonesia Pangkah Limited, all of the statement made and all of the
documents submitted with our proposal are true, duly authentic, legally obtained and issued and
currently in the possession of the undersigned. If any of the document submitted or the statement made is
proved to be counterfeit or untrue, without prejudice to any legal remedy that Saka (Indonesia-Pangkah)
Ltd may have, the undersigned shall be solely liable for any and all of administrative (will be excluded
from all procurement process in Saka for 2 years period) and/or criminal sanction as result there from
imposed by SKKMIGAS and/or the Government of the Republic of Indonesia.

The undersigned represents and warrants to Saka (Indonesia-Pangkah) Ltd that the undersigned has
power to make this statement and to perform the obligations under this statement and has taken all
necessary corporate or other actions to authorize the execution, delivery and performance of this
statement.

This statement is made by the duly authorized person on the date and year first written above for the
benefit of.

The undersigned,

(Stamp duty Rp. 6,000 )

Name : __________________
Title : __________________

Page 20 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

EXHIBIT 4
STATEMENT OF APPLICANT BUSINESS & LEGAL STATUS

On this _______day of __________ 2017 the undersigned:

Name :

Position :

Company :

Company Address :

Hereby states that:

1. I/my company am/is not declared as being bankrupt or the business activities thereof are being
restricted or being imposed a criminal sanction or in courts custody.

2. I have never subjected to punishment upon a courts decision for any action associated with my
professional conduit.

I shall assume responsibility and liability and shall accept any legal and financial consequences if the
information mentioned above is found to be incorrect.

The undersigned,

(Stamp duty Rp. 6,000)

Name : __________________

Title : __________________

Page 21 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

EXHIBIT 5
STATEMENT OF APPLICANT CONTRACTUAL PERFORMANCE

On this _______day of __________ 2017 the undersigned:

Name :

Position :

Company :

Company Address :

Hereby states that my Company stated above is not being decided as under Red Sanction of Saka
Indonesia Pangkah Limited, and/or decided as under Black Sanction of Other Company within Oil and
Gas Industry in Indonesia.

I shall assume responsibility and liability and shall accept any legal and financial consequences if the
information mentioned above is found to be incorrect.

The undersigned,

(Stamp duty Rp. 6,000)

Name : __________________

Title : __________________

Page 22 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

EXHIBIT 6
STATEMENT OF DOMESTIC COMPANY STATUS

Yang bertanda tangan dibawah ini ..[nama].., Notaris/Konsultan Hukum yang

memiliki kewenangan hukum berdasar

Menyatakan dengan sesungguhnya, berdasar pada hasil pengkajian yang dapat dipertanggungjawabkan,
serta dengan dilandasi rasa tanggungjawab pada kebenaran hukum dan rasa tanggungjawab pada
kedaulatan ekonomi Negara Republik Indonesia, bahwa:

PT. ..[nama] .. adalah benar dan berhak menyatakan diri sebagai

Perusahaan Dalam Negeri sesuai dengan kriteria yang diatur dalam Pedoman Pelaksanaan
Pengadaan Barang/Jasa Kontraktor KKS nomor 007Revisi-II/PTK/I/2011 yang telah
diamandemen dengan Surat Keputusan Kepala SKK Migas nomor 0066 /SKKO0000/2013/S0
tanggal 3 April 2013

1. Struktur kepemilikan sahan PT. ..[nama]..yang memiliki hak suara (voting rights), hak
dividend an hak Kendali Manajemen oleh warga Negara Indonesia (WNI), badan usaha milik Negara
(BUMN), badan usaha milik daerah (BUMD), pemerintah daerah atau Negara Republik Indonesia
adalah sebagai berikut:

Badan Usaha Langsung Tidak Langsung Melalui Badan Usaha

PT. pada
PT.
PT.. PT.. PT.. PT.. PT.. PT..
Saham WNI
1. Tuan/Nyonya.
- Langsung
- Tidak Langsung
Via PT..
Via PT..
- Jumlah Saham
Tidak Langsung
(a)

2. Tuan/Nyonya.
- Langsung
- Tidak Langsung
Via PT..
Via PT..
- Jumlah Saham
Tidak Langsung
(b)

3. Dan seterusnya

4. Jumlah Saham (a)+ (b)

dimiliki oleh WNI + (dst)
secara langsung = .%
& tidak
langsung pada
PT

Page 23 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

2. Struktur Dewan Direksi adalah sebagai berikut:

No Nama Status Bukti Diri

Kewarganegaraan (KTP / Passport)

Demikian pernyataan ini dibuat berdasar keadaan sesungguhnya dan tidak terkandung upaya untuk
memanipulasi keadaan demi keuntungan client.

Dibuat di.
Notaris/Konsultan Hukum

Tanda tangan

[ nama.]

Page 24 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

EXHIBIT 7
STATEMENT OF LOCAL CONTENT COMPLIANCE

BID TITLE. ________________________

BID NO. ______________________

I the undersigned, for and on behalf of,

Company :

Company Address :

Phone :

Facsimile :

(hereinafter called the "APPLICANT"),

Herewith irrevocably acknowledges, declares, warrants and guarantees that the percentage of Tingkat
Komponen Dalam Negeri (TKDN) for this tender shall not be less than ______% (_________________ Percent).

The APPLICANTs TKDN is calculated in accordance with the instructions as stipulated in the Supply
Chain Management Working Procedures for Production Sharing Contractor (PSC) No. PTK-
007/SKKO0000/2015/S0 (PTK 007) issued by Satuan Kerja Khusus Pelaksana Kegiatan Usaha Hulu
Minyak dan Gas Bumi (SKK Migas)

The undersigned,

(Stamp duty Rp. 6,000)

Name : __________________

Title : __________________

Page 25 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

EXHIBIT 8
STATEMENT OF PAKTA INTEGRITAS & KEPATUHAN TERHADAP UU TIPIKOR

Saya yang bertanda tangan di bawah ini:

Nama :
Jabatan :
Nama Perusahaan :
Alamat Perusahaan :

Sehubungan dengan keikutsertaan perusahaan kami dalam proses pengadaan barang/jasa untuk
pekerjaan Provision of _________________________________________________ No._______________ di Saka
Indonesia Pangkah Limited (SIPL), dengan ini kami menyatakan bahwa, sesuai dengan Undang-Undang
Nomor 31 Tahun 1999 Jo Undang-Undang Nomor 20 tahun 2001 Tentang Pemberantasan Tindak Pidana
Korupsi, saya atas nama perusahaan:

1. Tidak akan melakukan komunikasi yang mengarah kepada praktek Korupsi, Kolusi dan Nepotisme
(KKN) baik secara langsung atau tidak langsung;

2. Tidak akan melakukan praktek KKN baik secara langsung atau tidak langsung;

3. Akan melaporkan pada pihak yang berwenang apabila mengetahui ada indikasi KKN dalam proses
pengadaan ini;

4. Tidak memberi sesuatu kepada panitia pengadaan, karyawan, dan/atau manajemen SIPL serta
peserta lain yang berkaitan dengan proses pengadaan ini yang dapat dikategorikan sebagai suap
dan/atau gratifikasi;

5. Berjanji melaksanakan proses pengadaan secara bersih dan profesional dalam arti akan
mengerahkan semua kemampuan dan sumber daya secara optimal untuk memberikan hasil kerja
terbaik mulai dari penyiapan penawaran, pelaksanaan, dan penyelesaian pekerjaan/kegiatan ini;

6. Bersedia untuk dilakukan pemeriksaan kepatuhan terhadap Undang-Undang Tindak Pidana

Korupsi, Foreign Corrupt Practices Act (FCPA), dan/atau Anti-Bribery and Corruption (ABC) oleh
auditor independen yang ditunjuk oleh KKKS dan/atau SKK Migas, berdasarkan data hardcopy
dan data digital.

Apabila saya dan/atau perusahaan saya melanggar hal-hal yang telah dinyatakan dalam PAKTA
INTEGRITAS ini, kami bersedia dikenakan sanksi-sanksi baik yang bersifat administrasi atau pidana
sesuai dengan ketentuan perundang-undangan yang berlaku.

Jakarta, ________________20__

Rp6000 Duty Stamp

Tanda Tangan : ________________________

Nama : ________________________

Jabatan : ________________________

Page 26 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

EXHIBIT 9
STATEMENT OF EMPLOYING BANK WITH BUMN/BUMD STATUS

On this _______day of __________ 2017 the undersigned:

Name :
Position :
Company :
Company Address :

I, the undersigned, hereby confirm of having bank account in a Bank with BUMN/BUMD (State Owned
Company/District Owned Company) status that will be used for all payment transaction in the event our
company is appointed as successful Bidder for the Work.

Our bank account information is as follows:

Bank Account Name :

Account No. :
Bank Name :
Bank Address :
Swift Code :

The undersigned,

(Stamp duty Rp. 6,000)

Name : __________________

Title : __________________

Page 27 of 31
BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

EXHIBIT 10
STATEMENT OF BASIC ABILITY

The APPLICANTs Basic Ability is calculated in accordance with the instructions as stipulated in the
Supply Chain Management Working Procedures for Contractor of Cooperation Contract (KKKS) No. PTK-
007/SKKO0000/2015/S0 (PTK 007) issued by Satuan Kerja Khusus Pelaksana Kegiatan Usaha Hulu
Minyak dan Gas Bumi (SKK Migas)

Applicants name : Filled in by the APPLICANT

Bid Title Filled in by the APPLICANT
Bid Number Filled in by the APPLICANT

Highest value of similar services / projects in the last 7 years (NPt)*

Client Name : Filled in by the APPLICANT
Contract Number & Title: Filled in by the APPLICANT
Contract Value Filled in by the APPLICANT
Period (start end) Filled in by the APPLICANT

*: Attached related Contract/PO & proof of payment receipt or other valid document showing
value of completed work
NPt = the highest contract value, similar with the above tender, which has been completed within a period
of the last seven (7) years, in the form of:
Single Contract value for procurement of single activity/project or goods/ services with a
period of Contract of not more than twelve (12) months.
Group of Contract value for a period of one (1) calendar year (1 January to 31 December)
for the procurement of goods/services requirement group with a period of Contract of
more than twelve (12) months.
Calculation of KD:

KD = Factor** x NPt
Filled in by the APPLICANT = 5 x US$/IDRFilled in by the APPLICANT
= US$/IDRFilled in by the APPLICANT

KD = Kemampuan Dasar (Basic Ability) for procurement of goods/services or group of goods/services

requirement, with a period of more than 12 months, the minimum KD value shall be the same as the
estimate of procurement value average for a period of twelve (12) months;

In this matter acting in my below mentioned capacity and therefore for and on behalf of the above
mentioned company hereby acknowledges, declares and warrants that for the purpose of participating in
subject tender held by Saka Indonesia Pangkah Limited, all of the calculation of basic ability submitted
with our proposal are true, duly authentic, legally obtained and issued and currently in the possession of
the undersigned. If any of the document submitted or the statement made is proved to be counterfeit or
untrue, without prejudice to any legal remedy that Saka Indonesia Pangkah Limited may have, the
undersigned shall be solely liable for any and all of administrative (will be excluded from all procurement
process in Saka for 2 years period) and/or criminal sanction as result there from imposed by SKK Migas
and/or the Government of the Republic of Indonesia.

(Nama Perusahaan / Name of Company)

Rp 6,000
Stamp duty

________________
(Director)

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BID 17-0038 PART D
PROVISION OF INTEGRATED MANPOWER SERVICES LIST OF EXHIBIT FOR
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH PREQUALIFICATION FORM

EXHIBIT 11
CONSORTIUM DEFINITION

Provided in a separate document.

Page 29 of 31
BID 17-0038 PART E
PROVISION OF INTEGRATED MANPOWER SERVICES SCORING / PASSING GRADE SYSTEM
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

PART E
SCORING / PASSING GRADE SYSTEM

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BID 17-0038 PART E
PROVISION OF INTEGRATED MANPOWER SERVICES SCORING / PASSING GRADE SYSTEM
FOR ONSHORE & OFFSHORE FACILITIES OF UJUNG PANGKAH

NO CRITERIA SCORE CRITERIA

I ADMINISTRATION
1 LETTER OF APPLICANT 2
2 FORM OF PRE-QUALIFICATION QUESTIONNAIRE 8
3 PERMIT AND LICENSE
A. COPY OF AKTE NOTARIS 1
B. COPY OF DOMICILE LETTER 1
C. THE LIST OF SHARE HOLDER BOARD OF DIRECTORS & 1
MANAGEMENT
D. COPY OF APPOINTMENT AS INDONESIAN SOLE AGENT 1
FROM MANUFACATURE - IF APPLICABLE
E. COPY OF VALID TAX PAYER IDENTIFICATION (NPWP) & 1
PKP AVAILABILITY
F. COPY OF TAX PAYMENT RECEIPT FOR THE LATEST 3 1 &
MONTHS VALIDITY
G. COPY OF ASTEK / JAMSOSTEK 1 ( COMPLIANCE
4 SET OF STATEMENT LETTER FROM APPLICANT TO
A. STATEMENT LETTER FOR AUTHENTICITY DOCUMENT 2 REQUIREMENT
B. STATEMENT LETTER FOR APPLICANT BUSINESS AND 2 )
LEGAL STATUS
C. STATEMENT LETTER OF APPLICANT CONTRACTUAL 2
PERFORMANCE
D. STATEMENT LETTER FOR DOMESTIC COMP. STATUS 2
E. STATEMENT LETTER FOR LOCAL CONTENT COMPLIANCE 2
F. STATEMENT LETTER FOR PAKTA INTEGRITAS DAN 2
KEPATUHAN TERHADAP UU TIPIKOR
G. STTMNT. LETTER OF EMPLOYING BUMN/BUMD BANK 2
H. STATEMENT LETTER OF BASIC ABILITY 2
5 ORGANIZATION STRUCTURE 2
6 CONSORTIUM CLAUSE - IF APPLICABLE 5
40
II TECHNICAL
1 VALID BUSINESS PERMIT & LICENSE
A. SURAT IJIN OPERASIONAL PERUSAHAAN PENYEDIA 20
JASA PEKERJA ( SIO-PPJP ) ENDORSED BY KEMENTRIAN
TENAGA KERJA & TRANSMIGRASI PADA INSTANSI YANG
BERTANGGUNG JAWAB DI TINGKAT PROPINSI
B SAMPLE OF "SURAT BUKTI PENDAFTARAN KONTRAK 10
TENAGA KERJA" FOR THE PAST CONTRACT WITHIN
AVAILABILITY
WITHIN THE PREVIOUS 7 (SEVEN) YEARS
&
2 SAMPLE OF STRATEGY FOR COMPENSATION & BENEFIT
VALIDITY
MANAGEMENT SYSTEM
1 BPJS KETENAGA KERJAAN ( JHT, JKM, JKK ) 5
2 BPJS PENSIUN 5
3 BPJS KESEHATAN 5
4 VACATION ALLOWANCE 5
5 TUNJANGAN HARI KEAGAMAAN 5
6 SEVERANCE PAYMENT 5

KILLING POINT ("KP = FOR POINT 1A & 1B, AND 70% OF ITEM 2 ) 60
III EXPERIENCES
1 APPLICANT EXPERIENCES 30
LIST OF EXPERIENCE
A COMPANY, PHONE, FACSIMILE, C/P
B TITLE OF SUPPLY
AVAILABILITY
C PERIOD
&
D. QUANTITY & VALUE OF THE SUPPLIED VALVE
VALIDITY
EXPERIENCE SHALL MEET BELOW CRITERIA :
SIMILAR TO THE WORK WITHIN 7 (SEVEN) YEARS
2 SUCCESSFUL CONTRACT PERFORMANCE 20
A COMPANY ID, PHONE, FACSIMILE, C/P
B CONTRACT NO., CONTRACT TITLE, PERIOD
KILLING POINT ("KP" = 70% OF SCORE ) 50
V FINANCIAL CAPABILITY
AVAILABILITY,
1 BANK REFERENCE 5
VALIDITY
2 BANK ACCOUNT ( MUST BE BUMN BANK ) 5
KILLING POINT ("KP" ) FOR POINT #2 ONLY AT THE SCORE OF 5 ( "KP"= 5 ) 10

TOTAL SCORE 160

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