Version 1.

0 – 4 May 2018

Annex A –BAT ABAC Third Party Form

 Section 1 of this form (“Questions for the Third Party”) may be provided to and completed by
the Third Party.
 Sections 2 to 5 (“Payment Details”, “Background Checks”, “Details of the Proposal” and
“Other”) are to be completed internally by the BAT Proposer, not by the Third Party. However,
it may be necessary to ask the Third Party targeted questions to complete Sections 2 to 5 of
the form.
 The information in this form needs to be provided for all proposed Third Parties which are not
“automatically lower risk”.
 The collected information will be used to determine if the Third Party is Lower, Medium or
Higher Risk.
 The completed form must be retained in accordance with the procedure set out in Section 8.

P = Procurement/Business
Date completed: stakeholder (dependant on
who the Proposer is)
Completed by: S = Supplier
L = LEX

Request / Question Response

1. QUESTIONS FOR THE THIRD PARTY Who completes?

1.1 Name of Third Party. CV POETRA BAHAGIA SEJAHTERA P

1.2 Address: S
(a) trading address of -
Third Party; and
(b) all other known
JL KAKTUS NO. 7 KOMPLEK RUKO NO. 2 RT 003
addresses (such as
KELURAHAN GOMONG KECAMATAN
residential address in
SELEPARANG
case of individual or
registered address in
the case of corporate).

1.3 If individual: S
(a) full name;
CV POETRA BAHAGIA SEJAHTERA
(b) other name(s) known
ERWIN SAPUTRA ST,M.Sc
by;
INDONESIA
(c) nationality;
UTAN, 01 SEPTEMBER 1984
(d) date of birth;
INDONESIA
(e) country of residence;
and
(f) passport number (or -
other ID number).

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1.4 If corporate: S
(a) type of corporate PERSEROAN KOMANDITER (CV)
structure (e.g. limited
DIREKTUR : ERWIN SAPUTRA, ST, M.Sc
company,
partnership); KOMANDITER : ERNI HIDAYAT
(b) registered name(s); POETRA BAHAGIA SEJAHTERA
(c) any previous POETRA BAHAGIA SEJAHTERA
registered name(s) in
the past 12 months;
(d) any trading name(s) (if
different from PBS
registered name);
(e) previous trading PBS
name(s) in the past 12
months;
(f) place of incorporation; KOTA MATARAM
and
(g) company registered TDP - 23.07.3.46.00421
number, tax
IUJK – 1-007270-2-2307-00510
identification number,
and any other NPWP – 80.257.024.2-911.000
identifying number.
PPKP – S-36PKP/WPJ.31/KP.0103/2017

1.5 If corporate, the (i) full name,
(ii) other name(s) known by,
(iii) nationality, (iv) date of
birth (v) country of residence
and passport number (or
other ID number) of:
(i) CV POETRA BAHAGIA SEJAHTERA S
(ii) ERWIN SAPUTRA, ST, M.Sc
(iii) INDONESIA
(iv) UTAN, 01 SEPTEMBER 1984
(v) MATARAM DAN KTP - 5204060109840001

(a) the primary contact

person who will carry +6282168515168
out services for BAT;
(b) if different, the
corporate’s directors; KOMANDITER – ERNI HIDAYATI
and
(c) if different, the KOMANDITER – ERNI HIDAYATI
individual(s) that have
ultimate control /
ownership of the
company (i.e. with a
20% or greater

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Request / Question Response

holding in the
company).

1.6 In which jurisdiction(s) will PENGADAAN SUMUR BOR BESERTA P

the Third Party supply KELENGKAPANNYA – SERVICES
products or services to BAT /
supply BAT products or
services?

1.7 Has the Third Party been YA S

incorporated for less than 6
months?

1.8 Primary contact person and ERWIN SAPUTRA, ST, M.Sc – S

email address. POETRABAHAGIASEJAHTERA@GMAIL.COM

1.9 Third Party to provide copies YA S

(electronic or hard copy) of its
anti-bribery and corruption
procedures.

1.10 If engaged, would the Third YA S

Party comply with BAT’s SoBC
and Supplier Code of Conduct
(if it is a general supplier) or
Principles for Engagement (if
it is supplying engagement
services to BAT)?

1.11 Payment details:

(a) Name of bank;
(b) Bank branch address;
(c) Bank account number;
(d) Correspondent bank
name and address (if
known); and
(e) Sort code
(a) PT BANK NEGARA INDONESIA (PERSERO), Tbk
(b) BANK BNI KCP AIRLANGGA JL. AIRLANGGA
MATARAM, AIRLANGGA SQUARE RUKO KOTA
MATARAM, NUSA TENGGARA BARAT- 83125 -
Telepon : (0370)639387
(c) NOMOR REKENING : 1919190988
(d) BANK BNI KCP AIRLANGGA JL. AIRLANGGA
MATARAM, AIRLANGGA SQUARE RUKO KOTA
MATARAM, NUSA TENGGARA BARAT- 83125 -
Telepon : (0370)639387
(e) 710000005

2. PAYMENT DETAILS

2.1 BAT cost centre for Third BANK BNI KCP AIRLANGGA P/B
Party.

2.2 SAP Vendor number (if - P/B

available).

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Request / Question Response

2.3 Is Third Party proposed to be YA BERDASARKAN PROGRES LAPANGAN SEBESAR P/B
paid a fixed fee? If so, please 30%
enter amount and frequency
of payment.

2.4 Is the Third Party requesting CASH / CHEQUE – TIDAK MASALAH P/B
payment in cash or by
cheque?

2.5 Is it proposed the Third Party KINERJA (PERFOMANCE) P/B, assisted by L

will be paid a success fee, or
on the basis of outcomes or
performance?

2.6 Has the applicable BAT P/B

procurement procedure been
followed with respect to the
Third Party?
If not:
(a) Why not?; (a) SETUJU – SESUAI DENGAN PROSEDUR DARI
BAT
(b) What is the
justification for the
(b) BUKTI KERJA DAN GAMBAR PROGRES
proposed
DILAPANGAN
remuneration?;
(c) Include details of any (c) KONTRAK KERJA TERBARU DAN GAMBAR
tender process or any PROGRES
benchmarking
undertaken; and
(d) Is it in the view of the
Proposer at fair (d) YA
market value?

1. BACKGROUND CHECKS

1.1 Please complete a Third Party - L

screening database check
(e.g. World Check One) on the
Third Party.
Did the screening database
check identify any adverse
media concerning criminal or
unethical activity involving (i)
the Third Party (ii) the
primary contact person(s)
who will carry out services for
BAT (iii) any of its directors or
(iv) any of the individual/s
that you understand have
ultimate control / ownership

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Request / Question Response

of the company (“ultimate
beneficial owners”)1?
Are any of those in categories
(i) to (iv) above on any:
(a) sanctions list;
(b) Politically Exposed
Person list; or
(c) regulatory or law
enforcement list?
Please attach a copy of the
screening result.

1.2 If the screening database - L

check at 3.1 identified
adverse media concerning
criminal or unethical activity
involving (i) the Third Party (ii)
the primary contact person(s)
who will carry out services for
BAT (iii) any of its directors or
(iv) any of the ultimate
beneficial owners2, please
conduct a desk-based
internet search (e.g. Google)
against the names of those in
categories (i) to (iv) above.
Did the desk-based internet
search, identify any additional
adverse media concerning
criminal or unethical activity
concerning (i) the Third Party
(ii) the primary contact
person(s) who will carry out
services for BAT (iii) any of its
directors or (iv) any of the
ultimate beneficial owners3?
If so, please provide details.

1.3 Are you aware of (i) the Third - L

Party (ii) any of the
individual/s that you
understand to be the ultimate
beneficial owners4 (iii) any of

1
The Proposer is not required to list individuals with a less than 20% shareholding.
2
The Proposer is not required to search for individuals with a less than 20% shareholding.
3
The Proposer is not required to search for individuals with a less than 20% shareholding.
4
With a shareholding of 20% or more.

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its directors (iv) or the
primary contact person(s)
who will carry out services for
BAT having been charged
with a criminal offence? If so
provide details.

1.4 Does the Third Party have any TIDAK ADA P/B
connections to anyone at
BAT? For example, is it
owned by a BAT employee’s
family member?

1.5 Are you aware of any other TIDAK ADA P/B

particular concerns, including
security or compliance
concerns, in relation to the
Third Party? If so, please
explain.
2. DETAILS OF THE PROPOSAL

2.1 Which BAT entity is it - P/B

proposed will contract with
the Third Party?

2.2 BAT employee or contractor YA P/B

(Proposer) proposing use of
the Third Party.

2.3 Identified BAT Decision TIDAK P/B

Maker on whether to on-
board Third Party (must be
different from, and senior to,
the Proposer).

2.4 Detailed description of the SESUAI DENGAN PERMINTAAN BAT YAITU P/B
proposed services or activities PEMBUATAN SUMUR BESERTA RESEVOAR / ATAU
to be conducted by the Third PENAMPUNG AIR, MKSH
Party, including scope and
timing. Where possible,
please provide examples of
the type of work to be
undertaken by the Third
Party.

2.5 As part of its TIDAK P/B, assisted by L

activities/services for BAT,
will the Third Party interact
with any individuals,
employees or representatives
of:

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 local, regional or
national governments
or bodies (e.g. the
police or legislature);
 supra-national
governments or bodies
(e.g. the UN);
 political parties;
 judiciaries;
 entities wholly or
partly owned or
controlled by the
state); or
 ruling or royal
families?
If yes, please explain/provide
details.

2.6 Does the Third Party have any YA P/B, assisted by L

government connections or
are any retired public officials
working for the Third Party?

2.7 What is the commercial KARENA KEAHLIAN SESUAI BIDANGNYA P/B

justification for using the
Third Party?

2.8 How was the Third Party YA, DENGAN CARA ALAT, TENAGA, PENGALAMAN P/B
identified? If an external DAN DOKUMEN PENDUKUNG, MKSH
recommendation, please
provide details of the person
recommending’s name,
employer and role.
3. OTHER

3.1 Any other information you REKAM JEJAK PENGALAMAN, JUJUR DAN P/B
would like to note, or that PRODCVHKLEVHGFDFESIONAL
should be known about, that
has not been covered by the
preceding questions

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DECISION RELATED TO THE PROPOSED THIRD PARTY

DECISION MAKER DECISION AND REASONS

Decision

Decision Maker

Reasons

Signed:

Conditions attached
Date: 7 DESEMBER 2018

Printed name: ERWIN SAPUTRA, ST, M.Sc Comments

Title:DIREKTUR CV. POETRA BAHAGIA

SEJAHTERA

BAT Business Unit or Central Function: