Purch Doc : Form /PURCH/PA/SA

Status New Vendor

Date 17 June 2013

VENDOR APPLICATION FORM

IMPORTANT NOTES
Please read carefully

 To be completed by all vendors as an approved supplier;

 The questionnaire must be completed in full and be signed;
 A company profile may accompany

1. Company Name CV. ISA CIPTA

2. Contact Name IWAN HARTONO MULYANTO

3. Job Title DIREKTUR

4. Address PERUM CITRA 2 BLOK E6/10 RT.05/19

PEGADUNGAN KALIDERES

Town JAKARTA BARAT

Postal Code 11830

5. VAT Registration Number (if applicable)

6. Income tax reference number (NPWP) 05.924.236.2-085.000

7. Telephone 021-5446694

8. Fax/Hp 0818959889

9. E-mail address iwanhartono@live.com

10. Website (if applicable)

11. Number of full team employees 6

12. Bank Account Number 1795000064

13. Bank Account Name CV. ISA CIPTA

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 Purch Doc : Form /PURCH/PA/SA
Status New Vendor
Date 17 June 2013

Main Contact Person in your Company :

Name IWAN HARTONO MULYANTO

Position in the Company DIREKTUR

Cell phone number 0818959889

Fax Number 021-5446694

E-mail address iwanhartono@live.com

Contact Person (sales) in your Company :

Name MUKRI

Position in the Company SALES MANAGER

Cell phone number 081211616217

Fax Number 021-5446694

E-mail address Stanlie_kiung@yahoo.com

Trade Name :

Trade names Description

 
 
 
 
 
 
   
   
   

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 Purch Doc : Form /PURCH/PA/SA
Status New Vendor
Date 17 June 2013

List all partners, owners and shareholders

Name Position occupied in the Citizenship ID Number

enterprise/company
IWAN HARTONO DIREKTUR INDONESIA 3671040811800002
MULYANTO
MARISA PUSPITASARI KOMISARIS INDONESIA 3671045703830005

Business / Organization Information

1. What is the capacity of your plant WORKSHOP MACHINERY

2. What is the percentage of your products 2%

Sold to Nufarm against your total sales

3. Where do you find out about Nufarm BUSINESS RELATION

4. Do you have any family members working at Nufarm NO

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 Purch Doc : Form /PURCH/PA/SA
Status New Vendor
Date 17 June 2013

I/We the undersigned acknowledge (s) that the information furnished is true and correct.

President Director Date 20 OKTOBER 2016

Sales / Marketing Director / Manager Date 20 OKTOBER 2016

Comments / Notes / Suggestion for improvement:

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Please send your completed questionnaire to

PT. NUFARM INDONESIA
Attn. Enung Musthofa
Plaza Aminta 8th Fl. Suite 802

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 Purch Doc : Form /PURCH/PA/SA
Status New Vendor
Date 17 June 2013

Jl. Letjend TB. Simatupang Kav. 10

Jakarta 12310
And mark “strictly Confidential” in the envelope

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