AMNT-PUR-003-F008 Purchasing - PQQ-Prequalification - New Supplier - English

Operations Support and SCM Doc No: AMNT-PUR-003-
F008
Purchasing Page 1 of 7
Version: 1.0
Approval Date: 03 July 2019
Review Cycle: 3 years
Author: Supt. Procurement &
Purchasing-PQQ Prequalification contract
Approval: Manager
Procurement & contract
Supplier Pre-Qualification Questionnaire (PQQ)
1 BASIC DETAILS OF YOUR ORGANISATION

1.1 Name of the organization in whose name the PT. BINTANG ARTHA CEMERLANG
bid would be submitted:
1.2 Contact name for enquiries about this ANWAR SULIANTO
questionnaire:
1.3 Contact position (Job Title): PRESIDENT DIRECTOR
1.4 Address:
1.5 Telephone number:
1.6 Fax number:
1.7 E-mail address:
1.8 Website address (if any):

1.9 Date Company was established, Company 11/25/2015 - Company Regristration number
Registration number and expiry date (if this AHU-3591585.AH.01.11.TAHUN 2015
applies):
1.10 Other relent Regulatory Business
Registration numbers and expiry dates (if this
applies). Please specify registering body:
Other governing Industry Registrations or
1.11 Memberships and expiry dates. Please
specify registering body:
1.12 Registered address if different from the
above:
1.13 Tax Registration number: 74.681.039-9.036.000
KPP Pratama Jakarta Grogol Petamburan

1.14 Tax Office where tax is paid
1.14 Is your organization: (Please tick one) i) A public limited company?
ii) A limited company? √
iii) A partnership
iv) A sole trader
THIS DOCUMENT IS UNCONTROLLED IN HARD COPY FORMAT

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This material is proprietary and confidential to PT Amman Mineral Nusa Tenggara
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v) Other (please specify)

1.15 Name the owners (or the 3 largest Rudi Indrawan (Palembang, Sumatera Selatan,
shareholders) of the business and where Indonesia), Cuandi (Lahat, Sumatera Selatan,
(district, region, country) they are domiciled Indonesia), Anwar Sulianto (Jakarta, Indonesia)
for identity, social security and tax purposes.
1.16 Name of (ultimate) parent company (if this
---
applies):
1.17 Parent Company Registration number (if this ---
applies):
1.18 Is there any Government (or government controlled entity) Yes / No
investment, ownership, or management associated with your
company? If Yes, advise details.
2 FINANCIAL INFORMATION
2.1
What was your turnover in the last two years $ 2,126,735.14 for $ 2,330,102.37 for year
(if this applies)? year ended 12/31/2018 ended 12/31/2019
2.2 What was the pre-tax profit (or loss) for the
$535,218.06 for year $ 499,444.11 for year
last two years?
ended 12/31/2018 ended -12/31/2019
2.3 What was the organization’s net worth /
$ 653,486.57 for year $ 795,787.83 for year
shareholders funds (or net liabilities) at the
ended 12/31/2018 ended 12/31/2020
date of the latest accounts?
2.4 What is your present cash and credit position? $1,471,609.21 cash at
12/31/2019
Available credit facility
$1,327,810.12 at
12/31/2019
2.5 Has your organization met the terms of its banking facilities and loan Yes / No
agreements (if any) during the past year?
2.6 If “No” what were the reasons, and what has been done to put things right?
----
2.7 Has your organization met all its obligations to pay its creditors and staff Yes / No
on time during the past year?
2.8 If “No” please explain why not:
--
2.9 What is the name and branch of Name: Bank Central Asia
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Branch: Puri Indah

your bankers (who could provide a reference)?
Contact details: 288-320-6789
2.10 If asked would you be able to obtain a guarantee or performance bond? Yes / No
If yes, state from whom.
2.11 If asked, would you be able to provide at least one of the following?
A copy of your most recent audited accounts (for the last two years if Yes / No
this applies)
A statement (prepared in accordance with appropriate accounting Yes / No
standards) of your turnover, profit & loss account and cash flow for the
most recent year of trading
3 BUSINESS ACTIVITIES
3.1 What are the main business activities of your organization?
3.2 How many full time and part time employees does your organization Full time –
currently have? (If you are a sole trader, please say so) Part-time -
3.3
What is the size (M2) and location of your operating facilities
3.4
What percentage of facilities are owned vs leased
3.5 What is the value of owned equipment currently used to support

your operation
4 REFERENCES
Please provide details of three recent contracts that are relevant to the services you are seeking to
provide to PT Amman Mineral Nusa Tenggara Where possible at least one should be from the
public sector. If you cannot provide three references, please explain why.
Reference 1 Reference 2 Reference 3

4.1 Customer Organization
(name):
4.2 Customer contact name and
phone number:
4.3
Date contract awarded:

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4.4 Contract reference and brief

description:
4.5 Value:
4.6 Date contract was
completed:
4.7 Have you had any agreements terminated for poor performance in the Yes / No
last three years, or any agreements where damages have been claimed by
the agreement authority?
4.8 If “Yes”, please give details:
5 INSURANCE
Please provide details of your current insurance cover Value
5.1 Employer’s Liability: $-
5.2 Public or General Liability: $-
5.3 Auto Liability $-

5.4 Other (please provide details): Stock $ 500,000.00
5.5 If requested can you provide Insurers Certifications for these Yes/No (if Yes advise name of
covers insurer)
PT. Asuransi Buana Independent
6 QUALITY ASSURANCE
6.1 Yes / No
Does your organization hold a recognized quality management
certification for example BS/EN/ISO 9000 or equivalent?
6.2 Yes / No
If not, does your organization have a quality management system*?
6.3 If you do not have quality certification or a quality management system, please explain why:
Do you have a document control and records management system Yes / No
7 HEALTH & SAFETY

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What Health & Safety government regulations does your organization

7.1
focus on ensuring compliance with?
7.2 Does your organization have a written health and safety at work policy? Yes / No
If No explain why
7.3 Does your organization have a health and safety at work management Yes / No
system*? If No explain why
7.4 Does your organization train staff in Health and Safety? Yes / No
7.5 Does your organization train staff in Health and Safety according to their Yes / No
particular job?
7.6 Advise the number of lost workday cases (LTIs), the total number of days
lost, and the total employee hours worked during the last one-year period.
7.7 List any fatalities your firm has had in the last three (3) years. Include
location, findings of the investigative authority and corrective action.
8 EQUAL OPPORTUNITIES AND HUMAN RIGHTS

8.1 Does your organization have written equal opportunities and/or human Yes / No
rights policies, to avoid discrimination?
9 ENVIRONMENTAL MANAGEMENT
9.1 Yes / No
Does your organization have a written environmental management policy?
9.2 Yes / No
Does your organization have an environmental management system*?
9.3 List any major environmental incidents your firm has had in the past three
years. Include location, cause and corrective action.
9.4 Does your organization train employees in Environmental Management? Yes / No
10 COMMUNITY AND EXTERNAL RELATIONS

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10.1 Yes / No
Does your organization have a written community and external relations
management policy?
10.2 Yes / No
Does your organization have a community and external relations
management system*?
11 PROFESSIONAL AND BUSINESS STANDING
Do any of the following apply to your organization, or to (any of) the director(s) / partners /
proprietor(s)?
11.1 Is in a state of bankruptcy, insolvency, compulsory winding up, Yes / No
receivership, composition with creditors, or subject to relevant
proceedings
11.2 Yes / No
Has been convicted of a criminal offence related to business or
professional conduct
11.3 Yes / No
Has committed an act of grave misconduct in the course of business
11.4 Yes / No
Has not fulfilled obligations related to payment of social security or
workers compensation contributions
11.5 Has not fulfilled obligations related to payment of taxes Yes / No

11.6 Yes / No
Is guilty of misrepresentation in supplying information
11.7 Yes / No
Is not in possession of relevant licenses or membership of an appropriate
organization where required by law
11.8
If the answer to any of these is “Yes” please give brief details below, including what has been done
to put things right.
I declare that to the best of my knowledge the answers submitted in this PQQ (and any supporting
modules) are correct. I understand that the information will be used in the evaluation process to
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assess my organization’s suitability to be invited to bid for the PT Amman Mineral Nusa Tenggara
requirement.

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FORM COMPLETED BY (Must be Director or person who has POA – Power of Attorney)
12.1 Name:
12.2 Position (Job Title):
12.3 Date:
12.4 Telephone number:
12.5 Signature + stamp:
Notes:
* “system” means processes and procedures to ensure that the subject is properly managed. This
includes making sure that legal requirements are met.
INTERNAL USE PTAMNT
Endorsed/Recommended by Procurement and Contract
Position (Job Title) Date Signature

Name
Approved by Procurement and Contract Manager/Equivalent Position

Position (Job Title) Date Signature
Name:

7

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Operations Support and SCM Doc No: AMNT-PUR-003-

Supplier Pre-Qualification Questionnaire (PQQ)

1 BASIC DETAILS OF YOUR ORGANISATION

1.3 Contact position (Job Title): PRESIDENT DIRECTOR

1.5 Telephone number:

1.6 Fax number:

1.7 E-mail address:

1.8 Website address (if any):

1.13 Tax Registration number: 74.681.039-9.036.000

KPP Pratama Jakarta Grogol Petamburan

THIS DOCUMENT IS UNCONTROLLED IN HARD COPY FORMAT

v) Other (please specify)

Branch: Puri Indah

3.5 What is the value of owned equipment currently used to support

Reference 1 Reference 2 Reference 3

THIS DOCUMENT IS UNCONTROLLED IN HARD COPY FORMAT

4.4 Contract reference and brief

5.2 Public or General Liability: $-

5.3 Auto Liability $-

Do you have a document control and records management system Yes / No

7 HEALTH & SAFETY

THIS DOCUMENT IS UNCONTROLLED IN HARD COPY FORMAT

What Health & Safety government regulations does your organization

8 EQUAL OPPORTUNITIES AND HUMAN RIGHTS

9.4 Does your organization train employees in Environmental Management? Yes / No

10 COMMUNITY AND EXTERNAL RELATIONS

THIS DOCUMENT IS UNCONTROLLED IN HARD COPY FORMAT

11 PROFESSIONAL AND BUSINESS STANDING

11.5 Has not fulfilled obligations related to payment of taxes Yes / No

THIS DOCUMENT IS UNCONTROLLED IN HARD COPY FORMAT

12.2 Position (Job Title):

12.4 Telephone number:

12.5 Signature + stamp:

INTERNAL USE PTAMNT

Endorsed/Recommended by Procurement and Contract

Position (Job Title) Date Signature

Approved by Procurement and Contract Manager/Equivalent Position

THIS DOCUMENT IS UNCONTROLLED IN HARD COPY FORMAT

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