PT.

TANJUNG ENIM LESTARI PULP & PAPER Doc No POD/F/03

PO. BOX 16, NIRU-TEBAT AGUNG
MUARA ENIM, SOUTH SUMATRA, INDONESIA Issue Original
PHONE : (0713) 324150, 324160, 324040 Issue Date 18-Feb-13
FAX : (0713) 324180, 324181, 324182

VENDOR REGISTRATION FORM/FORMULIR PENDAFTARAN REKANAN

A. General Information of Company/ Informasi Umum Perusahaan

Name of Company/Nama Perusahaan :
Type of Business/Jenis Perusahaan :
Address/Alamat :

City/Kota :
Post Code/Kode Pos :
Telephone No/No. Telepon :
Format :
+(country code/kode negara)(area code/kode area)(phone no/no. telepon)
Facsimile No./No. Faksimili :
Format :
+(country code/kode negara)(area code/kode area)(facsimile no/no. Faksimili)
Website :
PO receiver/Penerima PO
Name/Nama :
Telephone No/No. Telepon :
Format :
+(country code/kode negara)(area code/kode area)(phone no/no. telepon)
Mobile Phone No./No. HP :
Format :
+(country code/kode negara)(area code/kode area)(phone no/no. telepon)

Contact Person/Pihak yang dihubungi

Name/Nama :
Telephone No/No. Telepon :
Format :
+(country code/kode negara)(area code/kode area)(phone no/no. telepon)
Mobile Phone No./No. HP :
Format :
+(country code/kode negara)(area code/kode area)(phone no/no. telepon)
Email Address/Alamat Email :

Banker/Bank
Name of Bank/Nama Bank :
Branch/Cabang :
Account No./No Rekening :

Payment Term/Waktu Pembayaran

B. Person In Charge / Pejabat yang Berwenang

(Director and/or Manager) / (Direktur dan/atau Manejer)
1. Sales and Marketing/Pemasaran
Name/Nama :
Designation/Jabatan :
Telephone/HP No. :
Format :
+(country code/kode negara)(area code/kode area)(phone no/no. telepon)
2. President Director/Presiden Direktur
Name/Nama :
Designation/Jabatan :
Telephone/HP No. :
Format :
+(country code/kode negara)(area code/kode area)(phone no/no. telepon)
Finance Director/Direktur Keuangan
Name/Nama :
Designation/Jabatan :
Telephone/HP No. :
Format :
+(country code/kode negara)(area code/kode area)(phone no/no. telepon)

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 PT. TANJUNG ENIM LESTARI PULP & PAPER
PO. BOX 16, NIRU-TEBAT AGUNG Doc No POD/F/03
MUARA ENIM, SOUTH SUMATRA, INDONESIA
Issue Original
PHONE : (0713) 324150, 324160, 324040
FAX : (0713) 324180, 324181, 324182 Issue Date 18-Feb-13

3. Owners / Pemilik Perusahaan

Name/Nama :
Ownership/Kepemilikan :

Owners/ Pemilik Perusahaan

Name/Nama :
Ownership/Kepemilikan :

C. Vendor Legal Information/Persyaratan Rekanan

(Please attached copies) / (Harap lampirkan salinan dokumen)
Established Since/Tanggal Pendirian :
Notarized by/Nama Notaris :
Deed No./No. Akta :
Date/Tanggal (dd/mm/yy) :
TGL BLN THN

SIUP/Nomor SIUP :
TDP/Nomor TDP :
SPPKP/Nomor SPPKP :
NPWP/Nomor NPWP :
Domicile/Domisili
a. Village / Kelurahan :
b. Number/Nomor :

D. Vendor Type of Business

Primary Business Type/Jenis Perusahaan
Manufacturer/Manufaktur
Trading/Perdagangan
Wholesaler/Keagenan
Distributor/Penyalur
Retailer/Pengecer
Service/Jasa
Others/Lain-lain (Please specify) / (Sebutkan) :

Category/Jenis barang
Stationery/Alat Tulis dan Keperluan Kanto r
Furniture/Mebel
Stationery/Alat tulis
Pantry Consumable/Kebutuhan Rumah Tangga
Others/Lain-lain (Please specify) / (Sebutkan) :

Raw material/Bahan Baku

Wood
Chemicals/Bahan kimia
Hydrogen peroxide
Phosporic Acid
Sulphuric Acid
HCL
Digester additive
Organic Deposit Control
Polymer
Amine
Zinc
Trisidium Phosphate
Polymer Dispersant
Sulfamic Acid
Biocide
Lime Stone
Silica (SiO2)
Others/Lain-lain (Please specify) / (Sebutkan) :

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 PT. TANJUNG ENIM LESTARI PULP & PAPER
PO. BOX 16, NIRU-TEBAT AGUNG Doc No POD/F/03
MUARA ENIM, SOUTH SUMATRA, INDONESIA Issue Original
PHONE : (0713) 324150, 324160, 324040 Issue Date 18-Feb-13
FAX : (0713) 324180, 324181, 324182

BBM and Energy/BBM dan Energi

LPG
Argon
Diesel oil
Oxygen Liquid
Kerosene
Natural gas
Palm fruit shell
Palm fruit stalk
Palm fruit fibre
Screened wood waste
Others/Lain-lain (Please specify) / (Sebutkan) :
Service/Jasa
Accountant/Akuntan
Fumigasi
Civil/Kontruksi dan bangunan
Consultant
Mechanical/mekanikal
Electrical/elektrikal
Others/Lain-lain (Please specify) / (Sebutkan) :

Lube and Grease/Minyak Pelumas

Medicine/Obat-obatan
Spare part/Suku cadang

Mechanical/Mekanik :
Main product :
Other product :

Electrical/Elektrik :
Main product :
Other product :

Instrument / Instrumen :
Main product :
Other product :

DCS / PLC
Main product :
Other product :

Heavy Equipment/Alat Berat

Main product :
Other product :

Safety Tools/Peralatan Keamanan

Main product :
Other product :

Others
Main product :
Other product :

Transportation/Transportasi
Inland/Darat
Sea/Laut
Air/Udara
Others/Lain-lain (Please specify) / (Sebutkan) :

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 PT. TANJUNG ENIM LESTARI PULP & PAPER
PO. BOX 16, NIRU-TEBAT AGUNG Doc No POD/F/03
MUARA ENIM, SOUTH SUMATRA, INDONESIA Issue Original
PHONE : (0713) 324150, 324160, 324040 Issue Date 18-Feb-13
FAX : (0713) 324180, 324181, 324182

E. Experiences/Pengalaman Kerja
(experience in past 2 years)

F. This form prepared by / Form ini di isi oleh

Name/Nama :
Designation/Jabatan :
Date/Tanggal :
Telephone No/No. Telepon :
Format :
+(country code/kode negara)(area code/kode area)(phone no/no. telepon)

G. Safety Concern/Prihal Keselamatan

Willing to comply with all general safety rules that apply in the PT.TEL such as; /Bersedia mematuhi seluruh peraturan umum safety yang berlaku
dilingkungan pabrik PT.TEL seperti;
- Wear Helm/Menggunakan Helmet.
- Wear safety shoes/Memakai sepatu safety.
- No smoking in any area/Tidak merokok disembarang tempat.
- No wear short pants/Tidak memakai celana pendek.
- Understand of safety first/Mengerti tentang keutamaan keselamatan kerja.

Willing to comply Personal Protective Equipment while unloading chemicals as masker, goggle, glove, and etc./Bersedia memakai Alat Pelindung
Diri (APD) saat pembongkaran bahan kimia B3, seperti Masker, Kaca Mata Safety, dan Sarung Tangan.

H. Environment Concern / Prihal Lingkungan

Willing to comply with all environment regulation in PT.TEL/Bersedia mematuhi seluruh peraturan tentang lingkungan di PT.TEL.
Willing to provide Material Safety Data Sheet (MSDS) for all B3 chemicals./Bersedia menyediakan Material Safety Data Sheet untuk seluruh bakah
kimia B3.
Willing to pick up all the used packaging of B3 chemicals if needed./Bersedia mengambil kembali kemasan bekas (botol, tabung, karung, dsb.)
bahan kimia B3 jika dibutuhkan.
Willing to maintain cleanliness in PT.TEL area by do not throw any garbage if entry of PT. TEL area./Bersedia menjaga kebersihan lingkungan
pabrik PT.Tel dengan tidak membuang seluruh sampah bekas jika sedang memasuki wilayah PT.TEL.
Willing to create the label of each B3 chemicals on packaging./Bersedia membuat label bahan kimia B3 di packaging masing-masing material.
Attention to chemical cues B3 item during the process of tender./Memperhatikan isyarat item bahan kimia B3 saat proses tender.

We hereby confirm that the following particulars declared above are true and accurate / Dengan ini kami menyatakan bahwa data-data diatas adalah
benar adanya.
Director's Signature and Company stamp/Tanda tangan Direktur dan Cap Perusahaan

,.....,

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