SUPPLIER SELECTION FORM

PLEASE COMPLETE IN FULL

(NOTE: Please provide CURRENT information)

I. SUPPLIER RESPONSE
1 Was response submitted on time ?
Date submitted documents :

2 Did mandatory requirement have been met? Please tick mark

Non Disclosure Agreement
Terms of Reference Approval
Request For Proposal
Legal Documents
Tax Identification Certificate
Bank Reference
Contractor Selection Form

II. RISK ASSESMENT/DUE DILIGENCE

1 CORPORATE STRUCTURE
A. Company Name

B Registered Business Address

Phone :
Fax :
Email Address :
Website :

C Contact Person in Charge :

Phone :
Fax :
Email Address :

D Constitution of Business (please tick relevant box)/Jenis Perusahaan

Limited Liability Company
Commercial Entity
Civil Partnership
Limited Partnership Company
Other Please specified

Page: 1
E Company History
Place of Incorporation :
Year of Incorporatiion :
Services offered :

1 Type of Business License :

2 Certification Number :
3 Expiration Date :
4 Business Licensing :
Agency/Instansi pemberi izin
Legal Basis
1 Deed of Establishment :
a. Number :
b. Date :
c. Notary ;
2 Company Registration
a.Number :
b.Date :
c. State Registered :
3 Tax Identification
a.Number :
b.Date :
c. State Registered :

F Commisioners, Board Directors, and Shareholders

Name of Commissioner
No. Name DOB ID Card Number Position
1
2
3
4
5

Name of Board of Directors

No. Name DOB ID Card Number Position
1
2
3
4
5

Page: 2
 List of Shareholders
No. Name DOB/DOEstablis ID Card Number Position
1 hment if
2
3
4
5

G Qualification
Do you have any special certification/qualification in providing the services/goods?
Y/N (circle yes or no)

2 BUSINESS STRATEGY & HEALTH

A What kind of product/services that most popular that you produce/sell?
Corporate Awarding
Product Launching
Gala Dinner
Creative Concept and Design
Advertising
Government Projects
MICE

B Please mentioned approximated number of clients who interested to buy/use your product!

C Any pending or recently settled litigation? Y/N (circle yes or no)

D Any regulatory and any diciplinary history? Y/N (circle yes or no)

3 EXPERIENCE & TECHNICAL COMPETENCE

Please mentioned the Best Experience Project /Year
1
2
3

Please mentioned your specialization:

Page: 3
4 WORK COMPETENCE & STABILITY
A. How many percent your staff turn over?

B Do you have program training to employee ? Y/N (circle yes or no)

5 FINANCIAL AND PAYMENT

A Does your company has profit for the last 5 (five) years? Y/N (circle yes or no)

B Please provide bank information for payment:

Beneficiary Name :
Name of Bank :
Branch :
Bank Address :
City :
Bank Account Number :
Swift Code :

6 RISK PROFILE
1 Services delivery (please tick mark)
In-House
Third-Party vendors
Both
Reason:

2 Quality Control of the Services

Special certification Y/N (circle yes or no)
Regular site inspection Y/N (circle yes or no)
3-D Design Y/N (circle yes or no)
Others, please explained

3 Technology
Do you use digital project management software? Y/N (circle yes or no)

4 Mock up.
Are you willing to make 3-D design? Y/N (circle yes or no)
If NO, please explain

Does 3-D design must be paid? Y/N (circle yes or no)

If YES, please explain

Page: 4
 5 Term of Payment
How long payment expected to be received after invoice submitted?

6 Bank Reference
Would you give us bank reference, if we think it's necessary to be submitted?
Y/N (circle yes or no)
If NO, please explain

7 Other Office location

Do you have branch office/workshop/warehouse/outlet?
Y/N (circle yes or no)
If YES, provide locations

7 CONTRACT TERM & CONDITION

1 Do you willing to pay pinalties if late delivery happened? Y/N (circle yes or no)
If NO, please explain

2 Name of authorized signer agreeement

Name :
Position :
Phone :
Fax :
Email Address :

8 POLICY & STANDARDS

1 Privacy Policy
a Do you have Privacy Policy & Standards?
Y/N (circle yes or no)
If NO, please explain

b Do you have the mechanism on how to handle confidential

information?
Y/N (circle yes or no)
If NO, please explain

c Do you have internal process on how to escalate any privacy incident

occurs in your
Y/N (circle business?
yes or no)
If NO, please explain

Page: 5
 2 Do you have Records Management Policy & Standards?
Y/N (circle yes or no)
If NO, please explain

3 Do you have Anti-Money Laundering (AML) / Anti-Terorist Financing

(ATF) Policyyes
Y/N (circle & Standards?
or no)
If NO, please explain

III. REFERENCE CHECKS

Please provide minimum 2 references clients .

No Name of Clients Contact Person Phone
1
2
3
If It's necessary, EBW Worldwide will contact those people for further reference.

We affirm that all particulars given above and attachedd herewith are correct.
We fully understand that only shortlisted compay would be invited for any bidding process.

Company's stamp & signature :

Name :
Date :

Page: 6