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FORMULIR DATA SUPPLIER

FORM OF SUPPLIER DATA

1 Nama Perusahaan
Company's Name
:

2 Profil Perusahaan
Company's Profile
:

Bidang Usaha
:
Line of Business

Mulai Menjalankan Kegiatan Usaha

:
Business Commencing Date

Produk/Jasa Utama
:
Main Products/Services

Produk/Jasa Lainnya
:
Others Products/Services

Kapasitas Produk/Jasa
:
Products/Services Capacities

Total Aktiva
:
Total Assets

5 Pelanggan Utama
:
Top 5 Customers

Susunan Pemegang Saham

:
Shareholders' Composition

Susunan Direksi
:
Board of Directors' Composition

3 Pihak Yang Dihubungi

Contact Person

Departemen Penjualan
Sales Department
Nama
:
Name

Jabatan
:
Positition

No. Telepon/Handphone
:
Phone Number/Handphone

Departemen Keuangan
Finance Department
Nama
:
Name

Jabatan
:
Positition

Telepon/Handphone
:
Phone Number/Handphone
4 Domilisi Perusahaan
Company's Domicile

Alamat Kantor Pabrik

: Office Factory
Address

Kota
:
City

Negara
Country

Kode Pos
:
Postal Code

No. Telepon
:
Phone Number

No. Faksimili
:
Faxcimile

Website/Email :

5 NPWP
Tax Identification Number
:
6 Alamat NPWP
Address Tax Identification Number
:
7 PKP
Taxable Entrepreneur
: Yes/No
8 NPKP
Taxable Entrepreneur Confirmation Number
: Yes/No
9 Lapor Surat Pemberitahuan Masa (SPM) PPN
Monthly VAT Tax Return
: Yes/No
10 Surat Pajak Tahunan (SPT)
Annual Tax Filing
: Yes/No
11 Tanda Terima Lapor SPT*
Receipt of Annual Tax Filing
: Yes/No

* Harap lampirkan foto copy Tanda Terima Lapor SPT terakhir

Please provide copy of Receipt of the latest Annual Tax Filing
12 Rekening Bank**
Bank Account
Mata Uang
: RUPIAH (IDR)
Currency
Nama Bank
:
Name of Bank

No. Rekening Bank

:
Bank Account Number

Atas Nama
:
Account Name

Alamat Bank
Bank Address
Cabang
Branch

Mata Uang Asing

:
Foreign Currency
Nama Bank
:
Name of Bank

No. Rekening Bank

:
Bank Account Number

Atas Nama
:
Account Name

Alamat Bank
Bank Address
Cabang
Branch
Swift Code
IBAN No. :
 13 Termin pembayaran (hari) :
Terms of Payment (days)

14 Mulai menjadi Supplier Indofood

Commencing Date Become Indofood's Supplier
: dd/mm/yy (....... Tahun) ........../........./......... (...... Years

** Harus sama dengan yang tercantum dalam invoice.

Must be the same with the Bank Account mentioned in the relevant invoice.

Data-data dan keterangan yang diberikan seperti tersebut di atas adalah benar; sesuai dengan kondisi yang sesungguhnya
dan dapat dipertanggungjawabkan serta dapat digunakan sebagai bukti dan dasar oleh PT Indofood Sukses Makmur Tbk
dan/atau anak perusahaan (Indofood Group) untuk keperluan pertimbangan, perencanaan, pelaksanaan dan evaluasi atas
transaksi antara supplier dengan Indofood Group. Supplier wajib untuk memberitahukan kepada Indofood Group dalam
waktu 3 (tiga) hari sejak terjadinya perubahan atas setiap data tersebut dengan mengisi, melengkapi dan mengirimkan form
pengkinian data supplier ini.
All data and information as provided above are correct, real, factual, accountable and can be used as a base and/or evidence by PT Indofood Group for
making consideration, planning, execution and evaluation of any transaction between Indofood Group and Supplier. Supplier must inform Indofood Group
within 3 (three) days upon the changes of any relevant data by fill up, complete and send this renewal form.

Jakarta, .............................................. Verified by,*

Date :
via:

materai 10.000

Tanda tangan Direksi & Cap Perusahaan Nama: Sulistyo Nugroho Nama: Mathilda Alimin
Signature and company's stamp Name Name
Nama: Jabatan : Factory Manager Jabatan : FAM
Name Title Title
Jabatan:
Title *Manager level *Manager level
 DAFTAR DOKUMEN PENDUKUNG

I. Dokumen Status Hukum & Pajak

Legal and Tax Documents

1 Surat Notifikasi yang dikeluarkan oleh Bank penerima pembayaran ;

Notification letter issued by Beneficiary Bank
2 Copy Akte Pendirian dan Perubahannya;
Copy of deed of establishment and its amandment of AoA
3 Copy Surat Ijin Usaha;
Copy of Business Licenses
4 Copy NPWP;
Copy of Tax Identidication Number
5 Copy TDP;
Copy of Company Registration
6 Copy SPM PPN;
Copy od Monthly VAT Tax Return
7 Copy Tanda terima lapor SPT;
Copy of Receipt of Annual Tax Filing

II. Dokumen Standard Mutu / Kualitas

Quality Standard Documents

1 Sertifikat Keagenan
Certificate Agency
2 Surat Penunjukan Distributor
Appointment as Distributors
3 Sertifikat Halal
Halal Certificate
4 Sertifikat ISO / HACCP
ISO/HACCP Certificate
5 Spesifikasi Produk
Product Specification
6 Sertifikat Analisis
Certificate of Analysis
7 Flow / Proses Produksi
Flow of Production Process
8 Persetujuan Mutu Jual Beli Bahan Baku
Quality approval of raw material selling
9 Material Safety Data Sheet
Material Safety Data Sheet

III. Dokumen Status Assets (khusus Transporter)

Assets Ownership Documents (especially for Transporter)
 1 Copy BPKB & STNK
Copy of vehicle ownership and vehicle registration
2 Status sewa kendaraan
Rental Lease Agreement
3 Copy Gross Akte & Surat Laik Laut (untuk Kapal Laut)
Copy of vessel registration and vessel sailing certificate

IV. Pernyataan Jaminan Keterbukaan Transaksi

V. Data Perusahaan
Company Data
1 Profil Perusahaan
Company Profile
- Struktur Ownership
Ownership Structure
- Struktur Management
Management Structure
- Detail Kapasitas Produksi
Detail of production capacities
- Lab / teknologi untuk pengawasan mutu
Laboratorium/Technology for quality control
2 Copy Laporan Keuangan Terakhir
Copy of Latest Annual Report
3 Katalog Produk
Product Catalogue
EN PENDUKUNG