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Formulir Pendaftaran Penyedia Barang/Jasa

Supplier Registration Form

TUJUAN / Objective

Alasan Penyampaian Formulir / Reason Permohonan Penyedia Baru / New Supplier Application
for Submission Perubahan / Changes or Revise

INFORMASI UMUM / General Information

Nama / Name      


Alamat / Address      
Kode Pos / Postal Code      
Phone & Fax Phone Number:       Fax Number:      
Kategory / Category Perseorangan / Individual
Badan Usaha / Business Entity
NPWP / Tax ID Number      
BIDANG USAHA / Business Line

Konsultan Hukum / Legal Consultant Asuransi / Insurance


Konsultan Teknis/Pengawas Proyek / Technical Consultant Layanan Online / Online Services
Konsultan Lainnya / Other Consultant Pelayanan Kesehatan / Health Services
Kantor Akuntan Publik / Public Accountant IT Software
Kantor Jasa Penilai Publik / Appraisal Consultant IT Hardware
Penerjemah / Translator Penyedia Tenaga Kerja / Labor Supply
Agen Perjalanan / Travel Agent Agen Iklan dan Media / Adverstising Agency
Transportasi Darat / Land Transportation Percetakan / Printing
Transportasi Laut / Sea Transportation Jasa Design / Designer
Notaris dan PPAT / Notary & PPAT Kontraktor Umum / General Contractor
Perdagangan Umum / General Trade Supply
Others (Specify): .........

DATA PENGADAAN / Procurement Data

Nama Kontak / Contact Person      


Korespondensi / Correspondence Email address:      
Phone Number:       Mobile Phone:      
Kontak Darurat / Emergency Contact      
Korespondensi / Correspondence Email address:      
Phone Number:       Mobile Phone:      

INFORMASI PERUSAHAAN / Company Information

Tahun Pendirian / Year Established      


Jumlah Karyawan / Number of Employee      
Jumlah Tenaga Ahli / Number of Expert      
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PT Sarana Multi Infrastruktur (Persero)
Formulir Pendaftaran Penyedia Barang/Jasa
Supplier Registration Form

Staff or Certified
Klien Utama 3 tahun terakhir/ Top Major 1.       3.      
Customers for the last 3 years 2.       4.      
Komposisi Komisaris, Direktur Utama, 1.       Commissioner
dan Direktur / Commisioners and BOD’s 2.       President Director
composition 3.       Director ........
4.       Director ........
5.       Director ........

TRANSAKSI PEMBAYARAN / Payment Transaction

Mata Uang / Currency Rupiah (IDR) US Dollar (USD)


Lainnya / Others : .........
Pemegang Rekening / Account Holder      
Nomor Rekening / Account Number      
Nama Bank / Bank Name       Cabang / Branch      
Alamat Bank / Bank Address      

DATA PENYEDIA / Supplier Data :

Indonesian Domicile
Kami, badan usaha yang didirikan berdasarkan hukum Republik Indonesia melampirkan salinan data sebagai berikut /
We, a business entity duly established under the Laws of Repulic of Indonesia, are enclosing the following copies of
data :
1. Akte Pendirian Perusahaan / Deed of Company Establishment No:       Date:      

2. Akte Perubahan Terakhir Perusahaan / Deed of Company’s Amendment No:       Date:      

3. Surat Keterangan Domilisi Perusahaan / Domicile Letter No:       Date:      

4. Nomor Pokok Wajib Pajak dan Pengukuhan PKP / Tax Identity Number No:       Date:      

5. Surat Izin Usaha / Business License No:       Date:      

6. Tanda Daftar Perusahaan / Certificate of Company Registration No:       Date:      

7. Surat Keanggotaan atau Asosiasi/Certificate of Membership or Association

8. Sertifikat dari Lembaga terkait / Professional Certification

9. Struktur Organisasi Perusahaan / Organization Structure

10. Profil Perusahaan / Company Profile

Overseas Domicile
Kami, badan usaha yang didirikan berdasarkan hukum ____________________ melampirkan salinan data sebagai
berikut / We, a business entity duly established under the Laws of _______________, are enclosing the following copies
of data :
1. Registration and Incorporation Certificate No:       Date:      

2. Article of Association No:       Date:      

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PT Sarana Multi Infrastruktur (Persero)
Formulir Pendaftaran Penyedia Barang/Jasa
Supplier Registration Form

3. Tax Residency Certificate No:       Date:      

4. DGT-1 Form or Directorate General of Taxes Form

5. Certificate of Membership or Association

6. Professional Certification

7. Organization Structure

8. Company Profile

PERNYATAAN / Statement
Dengan ini saya menyatakan bahwa :
I declare that :

1. Saya memiliki otorisasi untuk memberikan informasi diatas dan lainnya sesuai permintaan
I am authorised to provide the above information and others upon request.

2. Saya berminat menjadi Daftar Rekanan dan bersedia mentaati peraturan tentang Pedoman Pengadaan
Barang/ Jasa PT SMI dan peraturan perundang-undangan yang terkait dengan pengadaan
I intend to be listed at Supplier List and am ready to comply with the Regulation on Procurement
Guidelines of PT SMI and other provisions related to the procurement.

3. Saya tidak akan melakukan Korupsi, Kolusi, Nepotisme, kecurangan atau pelanggaran-pelangaran dalam
proses Pengadaan Barang/Jasa di PT SMI
I will not carry out any Corruptions, Collution, and Nepotism, frauds in the process of Procurement at PT
SMI.

Nama / Name       Tanggal / Date      


Jabatan / Job Title            
     
Tandatangan / Signature      
     

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PT Sarana Multi Infrastruktur (Persero)