Registered Office Contact Details CONTACT PERSON(S) - Please fill in as applicable to your company (insert additional lines if required)

Company Name Scope of Services Main Area(s) of

Company Name Title Post-nominals Key Point of
Abbreviation and/or Material Supply Operations First Name Middle Name(s)
(e.g. Ir., Prof., Dr, Family Name (e.g. MH, SH, Primary Business E-mail Personal E-mail Contact Secondary Passport
Address(es) Phone FAX (full first name, pls don't use (all names except the first and the last POSITION Direct Line National Identity Card #
Lord, Lady, Dame. initials) name)
(or Last Name) BE, BsC, PhD, HP / Mobile Phone (may be yahoo, gmail, hotmail or other) (Pls check all HP / Mobile Phone (solely for WNA)
etc) etc) applicable)

President Commissioner
Commissioner
Commissioner
Main Operations Office (if different from above) Commissioner
Address(es) Phone FAX Email Non-Managing Director, Member of Board of Directors
Non-Managing Director, Member of Board of Directors
Non-Managing Director, Member of Board of Directors
CEO (or Managing Director)
Warehouse (if any) Director, member of management team P
Address(es) Phone FAX Email Director, member of management team
Director, member of management team
General Manager
Head of Finance
Head of Operations
Registered Office Contact Details Head of Manufacturing P
Address(es) Phone FAX Email Head of Sales & Marketing
Business Development Manager P
Account or Sales Manager handling NSN
Program Manager P
Head of Heatlh & Safety P
Registered Office Contact Details Quality Manager
Address(es) Phone FAX Email Human Resources Manager
Legal Representative
Procurement Manager
Factory Manager
Training Manager
Registered Office Contact Details Warehouse Manager
Address(es) Phone FAX Email Logistics Manager
Operations Manager
Network Operations Co-ordinator
Field Operations Co-ordinator
Project Director
Registered Office Contact Details Project Manager
Address(es) Phone FAX Email Project Manager
Project Co-ordinator
Project Co-ordinator
Documentation Controller
Documentation Controller
 Item Info Description Remarks

Company Legal Establishment Details

Company Identification
Registered Company Name Nama perusahaan berdasarkan Akta Pendirian
Registered Company Trademarks Brand atau Trademark perusahaan
In-use company name / identification Nama yang biasanya di pakai untuk perusahaan
Company Type Bentuk Badan Usaha
Date of Company Establishment Tanggal Berdiri
Registered Company Domicile Alamat yang di Akta Pendirian
Building, office suite
Street Address
RT / RW Address
City
Region / Province
Country
Office Location
Latitude
Longitude
Company Contact Details
Contact Telephone Numbers for said office
General Telephone Number
General Fax Number
Other Telephone Number(s)
Other Fax Number(s)
Company Email Addresses
General Information
Sales & Marketing
General Management
Telecommunications Business
Company Website(s)
Main Company
Parent Company
Subsidiary Company
Partner or Associate Company
Key Point of Contact within Company
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Position & Title within company
Building, office suite
Street Address
RT / RW Address
City
Region / Province
Company Legal Establishment Details
Akte Notaris
 Item Info Description Remarks

Date of Akte Tanggal Akte Notaris

Contact Details of Lawyer who handled the company establishment
Company Name Nama perusahaan Notaris
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Position & Title within company
Building, office suite
Street Address
RT / RW Address
City
Region / Province
Country
Company Registration & License Information
Akte Notaris
Registered Business Purpose Bidang Usaha
Company Business Permit(s) Type or Letter of Trade License type Surat Ijin Usaha Perdagangan
Company Business Permit(s) Number or Letter of Trade License # Surat Ijin Usaha Perdagangan
Company Registration in the Chamber of Commerce Tanda Daftar Perusahaan
Company Registration # in the Chamber of Commerce # Tanda Daftar Perusahaan
National Agency permit type
National Agency permit #
Registered location of Domicile Kelurahan
# of domicile registration # Surat Keterangan Domisili Perusahan
Company Tax Registration Number NPWP = Nomor Peserta Wajib Pajak
Company Tax classification Surat Pengukuhan Kena Pajak
Main Bank Details
Main Bank Name Nama Bank yang
Main Bank Account Name
Main Bank Account Number (Local Currency)
Current Account Balance in this account
Average Account Balance in this account for last 6 months
Maximum Account Balance in this account for last 6 months
Minimum Account Balance in this account for last 6 months
Other Bank Account Number (Foreign Currency)
Currency of Other Bank Account Number
Main Bank Branch Name
Main Bank Branch Address
Main Bank SWIFT Code
Main Bank IBAN
Company Board of Directors & Commissioners
President Commissioner Penanggung Jawab
First Name
Middle Name
Last Name
 Item Info Description Remarks

Position & Title within company

Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Commissioner Penanggung Jawab
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Commissioner Penanggung Jawab
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
President Director Penanggung Jawab
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Director 1 Penanggung Jawab
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Director 2 Penanggung Jawab
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
 Item Info Description Remarks

Director 3 Penanggung Jawab

First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Director 4 Penanggung Jawab
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Director 5 Penanggung Jawab
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Director 6 Penanggung Jawab
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Company Senior Management Team
Country Manager or Business Unit / Division Manager (for large or multinational companies)
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Head of Finance (or Finance Manager)
First Name
Middle Name
Last Name
 Item Info Description Remarks

Position & Title within company

Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Head of Human Resources (or HRD Manager)
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Head of Operations (or Operations Manager or Programme Manager)
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Head of Quality, Health & Safety
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Head of Health & Safety (if position is separated from Quality)
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Head of Sales & Marketing
First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
 Item Info Description Remarks

Head of Business Development

First Name
Middle Name
Last Name
Position & Title within company
Contact Number (Mobile Phone)
Contact Number (Office Phone)
Company Email Address
Private Email Address
Company Branch Office, Warehouse and Factory Location & Contact Details
Branch Office Address
Building, office suite
Street Address
RT / RW Address
City
Region / Province
Country
Office Location
Latitude
Longitude
Contact Telephone Numbers for above office
General Telephone Number
General Fax Number
Other Telephone Number(s)
Other Fax Number(s)
Warehouse Address
Building, office suite
Street Address
RT / RW Address
City
Region / Province
Country
Warehouse Location
Latitude
Longitude
Contact Telephone Numbers for above office
General Telephone Number
General Fax Number
Other Telephone Number(s)
Other Fax Number(s)
Factory Address
Building, office suite
Street Address
RT / RW Address
City
Region / Province
Country
Factory Location
Latitude
Longitude
 Item Info Description Remarks

Contact Telephone Numbers for above factory

General Telephone Number
General Fax Number
Other Telephone Number(s)
Other Fax Number(s)
 Company Shareholder Information

Shareholder 1
First Name
Last Name
% Share of ownership
Shareholder 2
First Name
Last Name
% Share of ownership
Shareholder 3
First Name
Last Name
% Share of ownership
Shareholder 4
First Name
Last Name
% Share of ownership
Shareholder 5
First Name
Last Name
% Share of ownership
Shareholder 6
First Name
Last Name
% Share of ownership
Shareholder 7
First Name
Last Name
% Share of ownership
Shareholder 8
First Name
Last Name
% Share of ownership
Shareholder 9
First Name
Last Name
% Share of ownership
Shareholder 10
First Name
Last Name
% Share of ownership
Details

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%
Other Affiliated Companies by this shareholder
Nature of Affiliation
(e.g. owner, independent director, manager, etc)