Sponsorship Payment Template

This information will be used to register your company in the GEHC Supplier database. The information will not be divulgated to any other parties.

Supplier Details Help Notes

If any fields in this form do not apply to your company please enter NA
Country INDONESIA
Name PT. ARKAN JAYA NUSANTARA Name as it appears on Company W9 (USA)
Street Address JL PANGERAN HIDAYATULLAH RUKO BANUA ANYANo PO Box addresses, please provide location address
City BANJARMASIN
State/Province KALIMANTAN SELATAN Enter NA if not applicable
Postal (ZIP) Code 70121 Enter NA if not applicable

Contact Details Help Notes

Supplier Contact Name HAFIZ

Supplier Phone Country Code /Area Code 511 Ex: France:33687712345 (33=Country code) / US:262-555-1234 (262 = Area Code)
Supplier Phone Number (no extensions) 811509630
Supplier Fax Country/Area Code NA
Supplier Fax Number NA
Supplier Contact Email Address Hafiz@ajn-indonesia.co.id

Supplier Payment Details - Electronic Help Notes

Complete this section if payment will be received electronically, else leave blank and
provide details for payment by paper check
Bank Name BCA
Account Name ARKAN JAYA NUSANTARA,PT
Bank Address JL. BRIGJEND H. HASAN BASRI NO 045 KEL PANGERAN KEC BANJARMASIN UTARA
Bank City BANJARMASIN
Currency IDR
Bank Account Number 7215039889
SWIFT Code (Outside US & Canada) CENAIDJA Required for international payments and Non - US & Canada Banks

Supplier Payment Details - Paper Check Help Notes

Complete this section if payment will be received by paper check AND the address to
which payment must be sent differs from the company address above
Address to which payment will be sent JL PANGERAN HIDAYATULLAH RUKO BANUA ANYA
PO Box or street address as applicable
City BANJARMASIN
State/Province KALIMANTAN SELATAN Enter NA if not applicable
Country INDONESIA
Postal (ZIP) Code 70121 Enter NA if not applicable

FOR NON USA: Please send a copy of your company letterhead or TAX ID (NPWP) Request for this document complies with GEHC internal authenticity requirements.