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F.'---.-r pT. TAilJt ilc Eril LETSTAH pui.P & pApER Doc No POD'FlIxl
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ftioxE : (0713) az4tso, rEl4rto,
r.oiEsrA
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hsrp ebinal
lssue Date 18-FeE'13
FAX : (0/13) 3Ali80, 321'181. 32,1182

VENDOR REGISTRANON FORII'FORTIUUR PENDAFTARAN REKAT{AN

A. Genrrrl lnfomaoon of ConpE,rryl tn on ast Umam Po,r[/sahe'[,

ilan orcompenyt*',t. tuasa,,an , f.r-rnp..tl.cnt!.4..9-11.1:tf5-..r.ffr.t!!!:...P-Elt..?.Ltn!L...q.rs.$p.P.).....
T)De of BusineqvJenis Pe rush aa n
Addrcssy'erernat

CitylKo[a
Post Code/Kode Pos

Tolephone NdNo. Ierqpofl

Facsimile No"/rW. Faksimlll

Fomat:

Web6ite , :[ffi?ffi'E: ffil,ffiI* ::x"*]il l YT- lTlil

PO rucelwr/Faradina PO
NamdNarrE . F.trrtitM AL?l,r1
Tdephono No/rvo. Iereporl
Fomat:
+(country code/kode n€garaxerea code/kode aleafiphone ncr'no. telepon)
Mobll€ Phorc NoJNo. HP , . !. 9.29 5. 2.. :. !..831.:. ?1 9.9.
Format:
+(country codeikode negaraxare codeftode areaf,phom ndm. telopon)

Contaci P.nion Prhrt yaw dtlwbutrgl

Nam€/r\bfira
Telephorc No/rvo. Ierspo,
Format:
+(country code/lod€ n€garaxarsa codo/kode aEaxphono no/m. telspon)
irobde Pt\o{\e i.lo^lo, FIP t .!..?]fr 52. 1.|gji 3. : 9.193.
Format:
+(country qode/kode negarafiarea cod€/kode a,oaxphone Rc/no. telepon)
Email Address/Alamat Email : .?-5.1!!.C.4 l.ll.2 $m.?i.l :k1!!.
B.rlk rrArr*
Nam€ otBanu^rarna Banft , (1 :.Pt! !tE...f.4.1!.9,fl ...(. p..g.es.t p.a).. I.*tr
.

Brarrh/Cabang , ..qg r.r. n s.! rf A....9v.?...$....?.fi a.P I !I tl !! t! ....

Account No./rvo Rer(orrirrg ..1!.L. :..99.'-.8. 2 9.2LA2..:.8..... ".....................
'
Payment Term/waktu Pembalraran . i !.f.!rlr ..?9 rr 9.f. !:f . 9. n l! !:.?.r.9. n....
.

B. Person ln Ghargo rPldabaty.t g Bcr/emng

(Dirccnor andlor Matgget) I (Arektur cran/dtau Manajer)
'1. Sales and Msrkelingl Pernes,,ran
Namo/rvarna
DqBignation/JtDa0an
TektphondHP rvo. , .!.6.?.9.8?-..:.b.3 9.1..:..83.9.1..
Format:
+(country code/lodo negaraxar€a cod€/kode areaxphoile no/no. tolepon)
2. Prssident Drector/Prasi(hn DirEKur
Namo/rvar,a , ..hl!:#,|.S.. n-r1 fn !1.....
O€signation/Jabara,
Tdephone/HP lvo. , .!.9!?9.5.2..:.!E!tt..:. 9i.Q3.
Fomat:
+(country code/kode negaraflare code/kode ama[phone no/no. telepon)
Finance Director/Dr?ekfur Kauatgan
Namdrvama
O6ignation/Jabaran
TelephondHP /Vo.

+(country code/kde negaraxarea code,kode ar€axphone ndno. telepon)

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