FORMULIR IDENTITAS NASABAH

Client Indentification Form

Baru /New Lama /Renewal

Berdasarkan Undang-Undang No. 8 Tahun 2010 Tentang Tindak Pidana Pencucian Uang, Peraturan Menteri Keuangan No. 30/PMK.010/2010 tentang Prinsip Mengenal Nasabah
(PMN) bagi Lembaga Keuangan Non Bank (LKBN ) tentang Pedoman Pelaksanaan PMN, kepada setiap calon nasabah dan nasabah asuransi diwajibkan menjawab pertanyaan dan
melengkapi dokumen sebagaimana disebutkan di bawah ini.

Based on Law No. 8 Tahun 2010 Re Anti Money Laundering , Ministry of Finance Decree No. 30/PMK.010/2010 Re. Principles of Knowing Your Customer (KYC) for Financial
Institution Non Bank require to each prospective clients or clients obliged to response the questionnaire below :

NASABAH INSTANSI
Corporate Client

1 Nama Institusi /Perusahaan Bidang Usaha /Bussiness Sector

Company Name UD.ANEKA TEKNIK KBLI : 47793
2 Alamat Perusahaan Telephone :
Company Address Facsimile :
JL.HKSN KOMP. AMD PERMAI BLOK A23 Website :
NO.479 RT.022 KEL.ALALAK SELATAN
BANJARMASIN

3 Akte Pendirian dan Pengesahan dari

Menteri Hukum dan HAM / Terlampir / Attached
Article of Association
4 Surat Izin Usaha Perdagangan (SIUP) / Licence Terlampir / Attached
503-638

5 Tanda Daftar Perusahaan (TDP) /

Corporate Registeration No. Terlampir / Attached
16.10.5.47.11795

6 Domisili Perusahaan / Company Domicile Kota / City : Banjarmasin_______________ Kode Pos / Post
Code :__________
Telp / Phone : ________________ Ext _______

Terlampir / Attached

7 Laporan Keuangan / Annual Report Terlampir / Attached

8 Nomor Pokok Wajib Pajak / (NPWP)/Tax ID) Terlampir / Attached

16.638.346.3-371.000
9 Nama Direktur Utama/Presdir/Pemegang Kuasa
Director/President Director/Authorized Person
Name
YASMIN SUHARTIN

No. KTP/SIM/Paspor
ID/Driving Licence/Passport No.
No HP/Mobile number 081251042477
eMail/e-mail address anekateknikbjm@gmail.com

10 Sumber Penghasilan / Dana/ Hasil Usaha Lain-lain

Sources of Income
Income Others
11 Data Bank / Bank Details BCA
Nama Bank / Bank Name YASMIN SUHARTIN
No Rekening (Rps) /Account No. In IDR
No Rekening (US$) /Account No. In US$

12 Profil Perusahaan/Company Profile Terlampir/Attached

 INFORMASI TAMBAHAN
Additional Information

1 Polis lain yang telah dimiliki No. Jenis/Type Per. Asuransi /Insurance
Company

Other current Policies in Place No. Jenis/Type Per. Asuransi /Insurance

Company

2 Tujuan Menutup Asuransi / Perlindungan terhadap harta kekayaan / Asset Perusahaan

Purpose of having Insurance coverage Company Asset Protection
Lain-Lain /Others
_______________________________________________

3 Penutupan Asuransi untuk kepentingan Diri sendiri Mewakili Beneficiary Owner * - Lengkapi data
Acting for the interest of: Own interest On behalf of Beneficiary Owner* - Provide details
 Nama/Name :
 Alamat (sesuai ID)/
Address (as per ID)
 No Telp/Telp Number:
 Tempat & Tanggal Lahir/
Place and date of birth:
 Kewarganegaraan/
Nationality
 Surat Kuasa/ Terlampir/
Authorization Letter - Attached

Definition: Specimen Tanda Tangan Benefeciary Owner /

Benefical Owner (BO) shall be defined as any Specimen Beneficiary Owner signature
individual or legal entities which is the owner of
money, whom controlling transactions, whom giving
the power in the event of transaction and/or
controlling the operation through an institution or
agreement

Definisi:
Beneficial Owner (BO) adalah setiap orang atau
badan hukum yang memiliki dana, yang
mengendalikan transaksi Nasabah, yang memberikan
kuasa atas terjadinya suatu transaksi dan/atau yang
melakukan pengendalian melalui badan atau
perjanjian

Tgl /Date : ______________________

Singkatan / Abbreviation :
- KIMS : Kartu Identitas Menetap Sementara
- KITAS : Kartu Identitas Tinggal Sementara
- KITAP : Kartu Identitas Menetap

Nama Jelas / Cap Perusahaan

Name / Company stamp
Disclaimer:
In the event of inconsistency between the Bahasa Indonesia and English version, the Bahasa will prevail