Contract Requisition Form

CRF No: Originating Department/Section: Dept. Cost Center:

0005/DE-TE-
MLM/III/XXX/2013
Contract Title: Palembang Transportation Services
Previous Contract Number (if any) (for Amendment Request) :
PSC charged for this Service (Muralim, Tanjung Enim, Others (please specify)) : Tanjung Enim & Muralim
1. Work Classification 2. Funding Resources:
Investment CAPEX : Budgeted Unbudgeted
Operational OPEX : Budgeted Unbudgeted

WP&B required? Yes No Year Approved? Yes No Approval Date

AFE required? Yes No AFE No. Approved? Yes No Approval Date
Notes for AFE/WP&B :
2. Category Contract Value
USD 0 – USD 5000  Direct Appointment
USD 5000 – <USD 50,000  Direct Selection
USD 50,000 – <USD 5,000,000  Tender without BPMIGAS approval
USD 5,000,000 – above  Tender with BPMIGAS approval

3. Special Request Process Yes No

If the value of service/purchase more than the allowable procurement method above, please tick below box to categorized
the justification.

If the answer is yes, please attach the Interoffice Communication – DA/DS Justification Form to this document.

4. Est. Contract Effective 5. Owner Estimated Contract Value:

Date: IDR 992,399,190.94
1 July 2013
Contract Duration : 12 months

6. Scope of Work (Briefly describe the scope of work required for this contract. Use additional sheets, or provide
attachments as necessary)
a. CONTRACTOR shall be responsible to providing vehicles for specifically for the performance of the Services in
South Sumatera and surrounding area that meet operational standard and Health and Environment System of
Government of Indonesia and COMPANY to support COMPANY’s operation in operational area as specified in this
Contract with the quantity as determined by COMPANY in the Work Order.
11. Other Information (Note any additional information to assist with the preparation of the contract, if necessary)

Review/Approval Path Signature Date

Originator (End User) : 28 March 2013
Win Riyutara
Department Head (Line Manager of End User) :
Djoko Mulyono
Financial Authority Holder :
Priscilla Puspita

Received By Signature Date PSCM Specialist

Procurement Specialist : Procurement Method:
Ferdinand Valentino Tender D/S D/A

Additional Approval(s) Note (e.g. Bid Committee Challenge):

PLEASE ATTACHED THE PREPARED SCOPE OF WORK/SERVICES COMPLETED WITH THE RELEVANT EXHIBITS

This form is protected and shall be used solely for Dart Energy procurement activities. Changes to this form can only be made by the Procurement
Team. Questions regarding the use of this form can be addressed to Procurement Team.