SUPPLIER REGISTRATION FORM

Operation :
Department :

Bottler Distribution

(*) Supplier Full Name PT. BERKAH TEKNIK WIRATAMA mandatory

Alternate Name BTW
Classification Type mandatory List of Value
Suplier Site mandatory ( 3 charachter)
Jl Karang duren RT.03 RW.01 Kel. Karangduren Kec. Pakisaji Kab. Malang
(*) Address Line 1 mandatory
(*) Line 2
(*) Line 3
(*) City MALANG mandatory
(*) Postal Code 65141 mandatory
(*) Country INDONESIA mandatory
(*) Telephone mandatory
(*) Fax Number
(*) Contact Person HERMANSYAH mandatory (Last name, M, First)
(*) Phone Number of Contact Person 087884518688 mandatory
(*) Email Address MARKETING berkahteknikwiratama@gmail.com mandatory
Email Address FINANCE berkahteknikwiratama@gmail.com
(*) Payment Terms Due in 30 days (Default : 45)
(*) Payment Method Electronic (Default : Electronic)
(*) Invoice Currency Receipt (Default : IDR)
(*) Payment Currency (Default : IDR)
(*) Bank Name mandatory
(*) Bank Branch mandatory
(*) Bank Adress mandatory

(*) Bank Account Name mandatory

(*) Bank Account No mandatory
(*) Tax Registration (NPWP) 92.931.853.3-654.000 mandatory
(*) Mandatory to be filled

Requested by Reviewed by Approved by Registered by

Procurement Services National Procurement EDS OFFICERS

Date : Date Date Date

Registered by

Financial Accounting
Date

Classified - Restricted
New Supplier
TRADING PARTNER INFORMATION
Company Name
Trade Name
Supplier Type
Supplier Category
Supplier Sub Category
Assign to Org
NPWP Site (format: 99.999.999.9-999.999)
Address

City / Province
Zip Code
Country
Phone Number
Fax Number
Email Address Marketing
Email Address Finance
Insurance Information
CONTACT INFORMATION
Contact #1
First Name
Middle Name
Last Name
Title
Phone Number
PAYMENT INFORMATION
Invoice Match Option
Terms of Payment
Payment Method
BANK INFORMATION
Account #1
Bank Name
Branch
Account Name
Account Number
Currency
Request Type
Primary

GL ACCOUNT
Related Parties
Distribution Set
Pay Group
Withholding Tax
Invoice Currency
CCBI CONTACT INFORMATION
CCBI Commercial Representatives
CCBI Technical Representatives
Main User Department
History of Vendor Information
SUPPORTING DOCUMENT
Please tick if following supporting document is completed

Requestor Iwan Triwansah/IDN/SEA/CCA

Approval 1 Hasderyanto Nasution/IDN/SEA/CCA
Approval 2 Suharji Gasali/IDN/SEA/CCA
EDS Officer Ade Ardiansyah/IDN/SEA/CCA
SATRIO SEKTI NUGROHO
Satrio
GOODS
COLD DRINK EQUIPMENT - G
SUPPLIER ELECTRIC COOLER
National Office Distribution
71.620.666.9-941.000
Dusun Bara, Jalan Kampus Iqra
Namlea

Namlea
97571 BURU UTR TMR
Indonesia
0853 43194850

satriyo.namlea@gmail.com
satriyo.namlea@gmail.com

Satrio Sekti Nugroho

0853 - 43194850

Receipt
Due in 30 days
Electronic

BRI
Arga Pura
Satrio Sekti Nugroho
432001005718539
Rupiah
Add
Y

N
Rupiah

Wizni Fitrina Daulay

Ketut Nitia Negara
Business Services
 Approval Section
Submitted --- ###
Code Meaning
ADVERTISING & PROMOTION Supplier Advertising & Promotion
AIR CONDITIONER Supplier Air Conditioner
BARCODE Supplier Barcode
BOTTLE Supplier Bottle
BUILDING CONTRACTOR Supplier Building Contractor
CALIBRATION Supplier Calibration
CAN BODY Supplier Can Body
CARTON Supplier Carton
CDE - ICE BUCKET Supplier CDE - Ice Bucket
CDE - ICE CHEST Supplier CDE - Ice Chest
CDE - MOKI Supplier CDE - Moki
CDE - SPARE PART Supplier CDE - Spare Part
CHEMICAL Supplier Chemical
CLOSURE Supplier Closure
CO2 Supplier CO2
COLORANT Supplier Colorant
COMP Supplier Computer Supplies
CONCENTRATE Supplier Concentrate
CONSULTANT Supplier Consultant
CONTRACTOR Supplier Contractor
COURIER Supplier Courier
CRATE Supplier Crate
CROWN Supplier Crown
ELECTRIC COOLER Supplier Electric Cooler
ELECTRICITY Supplier Electricity
EMPLOYEE Employee
FORKLIFT Supplier Forklift
FORWARDER Supplier Forwarder
GLUE Supplier Glue
HOSPITAL Supplier Rumah Sakit
HOTEL Supplier Hotel
INSURANCE Supplier Insurance
LAB EQUIPMENT Supplier Lab Equipment
LABEL Supplier Label
MARINE FUEL OIL Supplier Marine Fuel Oil
MOTOR VEHICLE Supplier Motor Vehicle
OFFICE EQUIPMENT Supplier Office Equipment
OFFICE SUPPLIES Supplier Office Supplies
OIL Supplier Oil
OUTSIDE STORAGE Supplier Outside Storage
PAPER CUP Supplier Paper Cup
PAPER LABEL Supplier Paper Label
PLANT EQUIPMENT Supplier Plant Equipment
PLASTIC CRATE Supplier Plastic Crate
PLASTIC CUP Supplier Plastic Cup
PLASTIC PALLET Supplier Plastic Pallet
PRINTING Supplier Printing
PROMOTIONS Supplier Promotions
PROMOTIONS - PREMIUM Supplier Promotions - Premium
PUBLIC SECTOR COMPANIES Public Sector Companies
PULL TITE SEAL Supplier Pull Tite Seal
RADIO COMMUNICATION Supplier Radio Communication
RESIN Supplier Resin

Classified - Restricted
RGB Supplier RGB
SAFETY SHOES Supplier Safety Shoes
SHRINK WRAP Supplier Shrink Wrap
SPARE PART Supplier Spare Part
STRAPING BAND Supplier Straping Band
STRAW Supplier Straw
SUGAR Supplier Sugar
TAX AUTHORITY Tax Authority
TEA LEAF Supplier Tea Leaf
TETRA PAPER Supplier Tetra Paper
TEVI CUP Supplier Tevi Cup
TRANSPORTER Supplier Transporter
TRAVEL AGENT Supplier Travel Agent
UNIFORM Supplier Uniform
VENDOR Supplier
WAREHOUSING Supplier Warehousing

Classified - Restricted
Description Tag From To Enabled [ ]
Advertising & Promotion *
Air Conditioner *
Barcode *
Bottle * Supplier Barcode
Building Contractor *
Calibration *
Can Body *
Carton *
CDE - Ice Bucket *
CDE - Ice Chest *
CDE - Moki *
CDE - Spare Part *
Chemical *
Closure *
CO2 *
Colorant *
Supplier Computer Supplies 21-Apr-03 *
Concentrate *
Consultant *
Contractor *
Courier *
Crate *
Crown *
Electric Cooler *
Electricity *
Employee *
Forklift *
Forwarder *
Glue *
Hospital 2-May-03 *
Hotel 2-May-03 *
Insurance *
Lab Equipment *
Label *
Marine Fuel Oil *
Motor Vehicle *
Office Equipment *
Office Supplies *
Oil *
Outside Storage *
Paper Cup *
Paper Label *
Plant Equipment *
Plastic Crate *
Plastic Cup *
Plastic Pallet *
Printing *
Promotions *
Promotions - Premium *
Public Sector Companies
Pull Tite Seal *
Radio Communication *
Resin *

Classified - Restricted
RGB *
Safety Shoes *
Shrink Wrap *
Spare Part *
Straping Band *
Straw *
Sugar *
Tax Authority *
Tea Leaf *
Tetra Paper *
Tevi Cup *
Transporter *
Travel Agent *
Uniform *
Supplier *
Warehousing *

Classified - Restricted