BIODATA PERUSAHAAN

( EXTEND DATA VENDOR )

1. NAMA PERUSAHAAN : ...................................................................................................................................................................

2. ALAMAT PERUSAHAAN : ................................................................................................................................................................

............................................................................................................................................................................................................

KOTA ................................. KABUPATEN ............................... PROPINSI .......................................KODE POS : .........................

3. TELP. NO : ...........................................................................FACS. NO. : ………………….............................................................

4. EMAIL ............................................................................................................................

5. NPWP : .............................................................( No. TERBARU )

6. NO. REKENING BANK : 1. .............................. ……………………………….. Rp. VALAS : ........................

2. ........................................................................... Rp. VALAS : ........................

3. ........................................................................... Rp. VALAS : ......................

7. NAMA BANK : 1. .........................................................................................

2. ........................................................................................

3. .......................................................................................

8. ALAMAT LENGKAP BANK :

1. ................................................................................................................................................................

2. ................................................................................................................................................................

3. ................................................................................................................................................................

9. NAMA SALES PERSON : .................................. ……………………………………..NO. TELP. :…………… ....................................

10. NO. AKTE PENDIRIAN PERUSAHAAN : .........................................................................................................................................

11. TGL. AKTE PENDIRIAN PERUSAHAAN : ........................................................................................................................................

12. NO. PERUBAHAN : ...........................................................................................................................................................................

13. TGL. PERUBAHAN : .........................................................................................................................................................................

14. NAMA DIREKTUR ..........................................................................................................NO. TELP. : ..............................................

15. NAMA WKL. DIREKTUR ............................................................................................NO. TELP. :....................................... ............

16. NAMA PEMILIK SAHAM : 1....................................................... 2. .................................................................................

3. ...................................................... 4. .................................................................................

Unit Pemasaran IV
Jalan Pemuda 114
Semarang 50132 Indonesia
T +62 24 354 5341 F +62 24 354 9320
www.pertamina.com
17. SERTIFIKAT ASOSIASI PROFESI / PERUSAHAAN :

- NO. : ..........................................................................................................................................................................................

- TGL. DIKELUARKAN ................................................................................................................................................................

- MASA BERLAKU S/D ................................................................................................................................................................

18. SURAT KETERANGAN TERDAFTAR ( SKT ) :

- NO.SKT & No. VENDOR :.......................................................................................................................................................

- TGL. DIKELUARKAN ................................................................................................................................................................

- MASA BERLAKU S/D ................................................................................................................................................................

19. SUB. BIDANG / KLASIFIKASI : .............................................../ ......................................................../...............................................

................................................./...................................................../.........................................................../…...................................

20. KUALIFIKASI : .............................................................................................................

DEMIKIAN, BIO DATA INI DIBUAT DENGAN SEBENARNYA UNTUK DIPERGUNAKAN SEBAGAIMANA MESTINYA.

,................................ 20….

Requested By Direktur
Vendor Master
Meterai

ARIS AULIYA ...............................................................

Approved By

Unit Pemasaran IV
Jalan Pemuda 114
Semarang 50132 Indonesia
T +62 24 354 5341 F +62 24 354 9320
www.pertamina.com
 VALIDITAS DOKUMEN PENDUKUNG
Nama Perusahaan :
No. Vendor :

VALIDITY
NO DOKUMEN
(TGL. BERLAKU)
Surat Keterangan Terdaftar
1
SKT No :............................................ Tgl. Dikeluarkan :
Tanda Daftar Perusahaan
2
No : Tgl. Dikeluarkan :
Surat Ijin Usaha Perdagangan (SIUP)
3
No : Tgl. Dikeluarkan :
Sertifikat dari Asosiasi
4 Nama Asosiasi :
No : Tgl. Dikeluarkan :
5 Masa jabatan direksi (Khusus Untuk PT/Koperasi)
Surat Ijin Operasional Perusahaan Penyedia Jasa Pekerja/ Buruh dari
6 DISNAKER (untuk sub bidang Penyediaan Tenaga Kerja)
No : Tgl. Dikeluarkan :
Surat Ijin Usaha Jasa Konstruksi (SIUJK)
7
No : Tgl. Dikeluarkan :
Surat Ijin Industri dari DEPERINDAG (untuk bidang konveksi &
8 percetakan)
No : Tgl. Dikeluarkan :
Surat Keterangan Domisili
9
No : Tgl. Dikeluarkan :
Neraca perusahaan yang telah di Audit dan Opini dari KAP
10
(Khusus Perusahaan dengan Kualifikasi M & B)
Surat Penunjukkan Keagenan
11
No : Tgl. Dikeluarkan :

........................,......................................
CV/PT.......................................

................................................

NB : Formulir ini harus diisi sebagai kelengkapan Extend Data Vendor (mandatory data SAP)

Unit Pemasaran IV
Jalan Pemuda 114
Semarang 50132 Indonesia
T +62 24 354 5341 F +62 24 354 9320
www.pertamina.com