LAMPIRAN I

PERATURAN KEPALA BKPM NOMOR : TAHUN 2009 TANGGAL :

Bentuk Permohonan Pendaftaran Penanaman Modal (Investment Registration Application Form) PERMOHONAN PENDAFTARAN PENANAMAN MODAL (APPLICATION FOR INVESTMENT RE ISTRATION) Permohonan PENDAFTARAN PENANAMAN MODAL ini dia !"an "e#ada Kan$or Pe%a&anan Ter#ad! 'a$! Pin$! (PT'P) !n$!" ren*ana #enanaman moda% da%am ran+"a Undan+,Undan+ Nomor 2- Tah!n 200./ This INVESTMENT REGISTRATION is herewith submitted to the One Door Integrated Services Office for the ur ose of investment under the Investment !aw No" #$ of #%%&" I/ KETERANGAN PEMOHON I/ DETAI!S O' A((!I)ANT 0i"a #er!1ahaan 2e%!m 2er2adan h!"!m ma"a #emohon dii1i den+an da$a 1e%!r!h *a%on #eme+an+ 1aham #er!1ahaan &an+ a"an didiri"an/ If the com an* is not *et incor orated+ then the a ,icant data shou,d be fi,,ed out with a,, artici ant-s data of the com an* which is about to be estab,ished" 3/ Nama Per!1ahaan .tentatif/teta 010 : 444444444444444 Name of )om an* .tentative/fi2ed0 10 : 444444444444444 2/ Nama Pemohon : 444444444444444 Name of A ,icant : 444444444444444 5/ Pen&er$aan Da%am Moda% Per1eroan Shareho,ding .s0 Han&a dii1i !n$!" #er!1ahaan #enanaman moda% a1in+ 'or foreign direct investment com an* on,* a/ Pe1er$a A1in+ 'oreign Shareho,der .s0 A%ama$ dan Ne+ara A1a% Address and )ountr* of Origin R#6U'7 8) 9 88)

'!2 To$a%

der .Fa"1imi%i 'a2mi.ocation" 3/ 2/ Bidan+ U1aha !ine of 9usiness Lo"a1i Pro&e" (ro6ect !ocation Ka2!#a$en6Ko$a Regenc*/Munici a. address : 444444444444444 444444444444444 : 444444444444444 444444444444444 : 444444444444444 : 444444444444444 : 444444444444444 : 444444444444444 : 444444444444444 : 444444444444444 -/ A"$a Pendirian dan Per!2ahann&a (Nama No$ari1< Nomor dan Tan++a%) dan Pen+e1ahan Men$eri H!"!m dan HAM (Nomor dan Tan++a%0 : 444444444444444 5an*a diisi 6i3a erusahaan sudah berbadan ho3um )om an*-s Deed of Estab.d be s ecified for each sector/ .icab. moda.ah atas ni.e ..Number and Date0 7 444 Shou.it* : 444444444444444 : 444444444444444 : 444444444444444 : 444444444444444 .d be fi.embar saham/the ercentage is u on the nomina. not sheet of share .ine of business and/or for each .mai% E4mai.s0 */ To$a% ( a : 2 ) 10 88) A%ama$ Address R#6U'7 8) 9 88) 3009 .anned to cover more than one sector/ .u/stri e which is not a rosentase ada.isation from the Minister of !aw and 5uman Rights .ai nomina..ine of business+ . share of ca ita.ine of business and/or .read* incor orated II/ KETERANGAN REN=ANA PENANAMAN MODAL DES)RI(TION O' INVESTMENT/(RO8E)T (!AN 0i"a #enanaman moda% &an+ diren*ana"an a"an men*a"!# %e2ih dari 1a$! 2idan+ !1aha dan6a$a! diren*ana"an a"an 2erada di %e2ih dari 1a$! Ka2!#a$en6Ko$a a$a! %e2ih dari 1a$! Pro>in1i< ma"a ren*ana "e+ia$an (2idan+ !1aha< %o"a1i < eni16"a#a1i$a1 #rod!"1i dan ni%ai in>e1$a1i) har!1 dirin*i !n$!" 1e$ia# 2idan+ !1aha dan6a$a! !n$!" 1e$ia# %o"a1i/ If the ro osed investment/ ro6ect is .it* or more than one (rovince+ then the investment/ ro6ect .E.ocate in more than one Regenc*/Munici a.Nomor Te%e#on (hone number .ishment and its Amendment .2 2/ Pe1er$a Indone1ia Indonesian Shareho.ocation+ t* e/ roduction ca acit* and investment funds0 shou.an . saham bu3an .Name+ Notar* and Date0 and !ega.e coret *ang tida3 er.anned to ./ A%ama$ Kore1#onden1i )orres ondence Address .ed out if the com an* is a.

ater" 4444444444//<444/2044// Pemohon< A .the artici ants0 are res onsib.R /.icants or theirs re resentative which is authori>ed b* the (ower of Attorne* with sufficient stam dut* and =e . a .uding a./ 5/ In>e1$a1i (R#6U'7)8) 10 coret *ang tida3 er.assification of Indonesia 9usiness 'ie. attached documents/ data or submitted .u : : 444444444444// 4 444444444444// 4 Investment .@a"$! da#a$ di#er$an++!n+ a@a2"an $erma1!" do"!men6da$a 2ai" &an+ $er%am#ir ma!#!n &an+ di1am#ai"an "em!dian/ =e ac3now.Standard ).e PERN?ATAAN DE)!ARATION Kami men&a$a"an 2ah@a #ermohonan ini di2!a$ den+an 2enar< di$anda$an+ani o%eh 1e%!r!h #emohon a$a! "!a1an&a di a$a1 ma$erai &an+ *!"!# dan 1e@a"$!.* e2ecuted+ signed b* a.edge that this a .icant Ma$erai R#/ A/000<. Stam Dut* of R " ?"%%%+%% 4444444/444444 Tanda$an+an dan Nama e%a1 Name and Signature .nit )a acit* Ke$eran+an Remar3 .* and du.icab.eteness inc...S<0 10 10 stri e which is not a .e for its accurac*+ correctness and com .d0 : 444444444444444 : 444444444444444 : : 'a$!an Ka#a1i$a1 .5 Pro>in1i (rovince 5/ Prod!"1i Per Tah!n (roduction er :ear 0eni1 Baran+60a1a T* e of Goods/Services KBLI .ication has been ro er.

A .ations in 9ahasa from sworn trans.osures @ Lampiran : Enclos!res " 3/ '!ra$ dari in1$an1i #emerin$ah ne+ara &an+ 2er1an+"!$an a$a! 1!ra$ &an+ di"e%!ar"an o%eh Ked!$aan Be1ar6"an$or #er@a"i%an ne+ara &an+ 2er1an+"!$an di Indone1ia !n$!" #emohon ada%ah Pemerin$ah Ne+ara LainB !etter of recommendation from the re.ator if the a .e of Association0 da%am 2aha1a In++ri1 a$a! $er emahann&a da%am 2aha1a Indone1ia dari #en$er emah $er1!m#ah !n$!" #emohon ada%ah 2adan !1aha a1in+B )o * of Artic.icant is The Government of another countr*A 2/ Re"aman #a1#or &an+ ma1ih 2er%a"! !n$!" #emohon #er1eoran+an a1in+B )o * of va.ated countr* or .A ada%ah 5/ Re"aman An++aran Da1ar (Artic.icant is foreign com an*A .id ass ort if the a .e of Association of the com an* in Eng..BT(0 if the a individua.icant is foreign individua./ Re"aman Kar$! Tanda Pend!d!" (KTP) &an+ ma1ih 2er%a"! !n$!" #emohon ada%ah #er1eoran+an Indone1iaB )o * of va.ish or its trans. Lam#iran/Enc.ated countr* in Indonesia if the a .icant is Indonesian .id Identit* )ard .etter which is issued b* the Embass*/ Re resentative Office of the re.

aw of Re ub.ation .ic of IndonesiaA A/ Re"aman Nomor Po"o" Ca i2 Pa a" (NPCP) 2ai" !n$!" #emohon ada%ah #er1eoran+an Indone1ia ma!#!n 2adan !1aha Indone1iaB )o * of Ta2 Registration )ode Number .e of Estab.icant+ either for Indonesian individua.icants .s0 and a rova./ Permohonan di$anda$an+ani di a$a1 ma$erai *!"!# o%eh 1e%!r!h #emohon (2i%a #er!1ahaan 2e%!m 2er2adan h!"!m) a$a! o%eh dire"1i #er!1ahaan (2i%a #er!1ahaan 1!dah 2er2adan h!"!m) di%en+"a#i '!ra$ K!a1a 2erma$erai *!"!# !n$!" #en+!r!1an #ermohonan &an+ $ida" di%a"!"an 1e*ara %an+1!n+ o%eh #emohon6dire"1i #er!1ahaan/ .ated in this regu.* and du.if the com an* is a.* regu.aw of Re ub. rovisions concerning the (ower of Attorne* is strict. a .d be ro er.- -/ Re"aman A"$a Pendirian Per!1ahaan dan #er!2ahann&a 2e1er$a #en+e1ahan dari Men$eri H!"!m dan Ha" A1a1i Man!1ia !n$!" #emohon ada%ah 2adan !1aha Indone1iaB )o * of Artic. ?C (eraturan ini0" This a .if the com an* is not *et incor orated0 or b* the com an*-s 9oard of Directors .ication if the a . or com an* which is incor orated under the ..e ?C0" BADAN KOORDINA'I PENANAMAN MODAL KEPALA< GITA CIR0ACAN .icant is re resented b* another art* .ication shou.N(=(0 for the a .ic of IndonesiaA .icant is incor orated under the .3etentuan tentang surat 3uasa diatur ada (asa.* signed with sufficient stam dut* b* a.ishment of the com an* and an* amendment . form the Minister of !aw and 5uman Rights if the a .read* incor orated0 attached with (ower of Attorne* with sufficient stam dut* from whom signs and/or submits the a .artic.

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