DATE : / /

FORM SUPPLIERS - FOREIGN

BILL TO THE NAME OF: SUPERMERCADOS PERUANOS S.A. - RUC 20100070970

ADDRESS: CALLE MORELLI 181 2DO PISO - SAN BORJA

I.- GENERAL INFORMATION

CORPORATION NAME: NIF NUMBER 1

LEGAL ADDRESS:

STATE: COUNTRY: POSTAL CODE :

CONTACT NAME: CONTACT E-MAIL:

PHONE NUMBER: FAX:

PAYMENT CONDITION:
FORM OF PAYMENT: TYPE OF PAYMENT:

TRANSFER LETTER OF CREDIT SHA OUR BEN

PAYMENT TERM (DAYS): CURRENCY OF PURCHASE:

BANK DETAILS FOR TRANSFER PAYMENT:

NAME OF BANK:

SWIFT OF BANK: BANK ACCOUNT:

II.- COMMERCIAL INFORMATION (To be filled by Supermercados Peruanos S.A.)

NAME OF BUYER:

TYPE OF SUPPLIER: RETAIL NO RETAIL

TYPE OF MANAGEMENT:
INCORPORATION
CHANGE OF CORPORATE NAME FUSION LIQUIDAT OTHERS
INFORMATION UPDATE (ADDRESS, PHONE NUMBER E-MAIL) :

III.- ACCOUNT MANAGEMENT INFORMATION (To be filled by Supermercados Peruanos S.A. - Registro de Compras)
GRUPO DE CUENTA ACREEDOR:
CUENTA ASOCIADA:
GRUPO DE TESORERIA:

OBLIGATORY ATTACH A COPY OF THE DOCUMENTS NEEDED FOR SPSA

RETAIL / NO RETAIL
1. PROOF OF PAYMENT (COMMERCIAL INVOICE)

INCORPORATION / CHANGE OF CORPORATE NAME

1. FORM SUPPLIERS

NAME AND AUTHORIZED SIGNATURE - SUPPLIER NAME AND SIGNATURE OF PRODUCT MANAGER - SPSA
JOB POSITION: JOB POSITION:

SIGNATURE OF IMPORTS MANAGER

REVISED AND REGISTERED

VERIFICATION OF BILLS - SPSA / /
COORDINATOR OF TREASURY - SPSA

OBSERVATIONS:

1
NIF: Número de identificacion fiscal (Fiscal Identification Number)