PRE-QUALIFICATION (PQ)/ PRA-KUALIFIKASI

EQUIPMENT CONSULTANT
(EQC)

ESTABLISHMENT OF UNIVERSITY OF BENGKULU’S

HOSPITAL PROJECT

THE SAUDI FUND FOR DEVELOPMENT (SFD)

SFD LOAN NO. 12/756

Ministry of Education, Culture, Research and Technology

Directorate General of Higher Education
August 2021
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Table of Contents

I. NOTICE OF PRE-QUALIFICATION ................................................................................... 1

II. INSTRUCTIONS FOR APPLICATIONS OF PRE-QUALIFICATION .......................... 2
A. General ................................................................................................................................. 2
B. Submission of Application for Pre-Qualification ................................................................ 2
C. Pre-Qualification Questionnaire .......................................................................................... 4
D. Evaluation of Application for Pre-Qualification ................................................................ 5
III. Form Pre-Qulification .............................................................................................................. 8
A. Form I - Letter of Application ............................................................................................ 9
B. Form II– General Information .......................................................................................... 11
C. Form III – Legal Administration Data .............................................................................. 12
D. Form IV– Financial Data .................................................................................................. 12
E. Form V - Professional Staff & Supporting Professional Staff ......................................... 15
F. Form VI – Facilities of The Firm ..................................................................................... 16
G. Form VII – Experience Data ............................................................................................. 17
H. Form VIII – Proposed Site Organization .......................................................................... 21
I. Form IX – Association Data ............................................................................................. 22
J. Form X– Integrity Pact ..................................................................................................... 24
IV. Appendix 1: Professional Staff & Supporting Professional Staff....................................... 26

i

I. NOTICE OF PRE-QUALIFICATION
1. The government of the Republic of
Indonesia, through the Ministry of
finance, has received financial
assistance from Saudi Fund for
Development (SFD) toward the cost of
The Establishment of University of
Bengkulu’s Hospital, SFD LOAN No.
12/756 and it is intended that part of
the proceeds of this loan will be
applied to eligible payments under the
contract for which this invitation to
pre-qualify is issued.
2. The Bid Committee under the
Ministry of Education, Culture,
Research and Technology intends to
pre-qualify consultants for the work
package of Equipment Consultant
(EQC) to support Establishment of
University of Bengkulu’s Hospital,
SFD LOAN No. 12/756.
3. Pre-Qualification is “open to
international” firms with preference to
National and Kingdom of Saudi
Arabia consultant that satisfies the
qualification according to guidelines
for the procurement of consultants
under SFD, First Edition 1995.
4. The consultant who is eligible and
fulfilled the criteria may register
oneself and obtain a pre-qualification
document in the hard-copy form from
the office POKJA (Procurement Unit)
University of Bengkulu. Address:
University of Bengkulu, Rectorate
Building, 2nd Floor, Ruang Rapat 1. Jl.
WR. Supratman, Kandang Limun,
Kota Bengkulu, Ph. +62 736-21170,
21884 Fax-+62 736-22105. Email:
pokjaeqc@unib.ac.id, or sign up
through website
https://pmursptn.unib.ac.id/eqc/ to
collect the soft-copy document.
Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756
I. PENGUMUMAN PRA-KUALIFIKASI
1. Pemerintah Republik Indonesia, melalui
Kementerian Keuangan telah menerima
bantuan Keuangan dari The Saudi Funds
for Development (SFD) untuk membiayai
Proyek Pembangunan Rumah Sakit
Universitas Bengkulu, SFD LOAN No.
12/756 dan sebagian dari bantuan ini akan
digunakan untuk membayar kontrak yang
tercantum dalam undangan pra-
kualifikasi.
2. Kelompok Kerja (POKJA) Universitas
Bengkulu Kementerian Pendidikan,
Kebudayaan Riset dan Teknologi akan
melakukan pra-kualifikasi konsultan
untuk paket pekerjaan Konsultan
Peralatan untuk mendukung
Pembangunan Rumah Sakit Universitas
Bengkulu, SFD LOAN No. 12/756
3. Pra-Kualifikasi ini “terbuka untuk umum”
bagi konsultan Internasional dengan
mengutamakan konsultan Nasional
Indonesia dan Kerajaan Arab Saudi
dengan kualifikasi sesuai dengan
petunjuk penggunaan konsultan dibawah
SFD Edisi Pertama 1995
4. Konsultan yang berminat dan memenuhi
persyaratan dapat mendaftar dan
memperoleh hardcopy dokumen pra-
kualifikasi dengan cara datang ke Kantor
POKJA (Kelompok Kerja) Universitas
Bengkulu, Gedung Rektorat Lantai 2,
Ruang Rapat 1. Jl. W.R.Supratman
Kandang Limun, Kota Bengkulu, Fax-
+62736-22105, dan email
pokjaeqc@unib.ac.id atau mendaftar
melalui https://pmursptn.unib.ac.id/eqc/
untuk mendapatkan softcopy dokumen
1

5. Application of pre-qualification can be
directly submitted or sent (via postal
services) to the office of POKJA
(Procurement Unit) University of
Bengkulu. Address: University of
Bengkulu, Rectorate Building, 2nd
Floor, Ruang Rapat 1. Jl. WR.
Supratman, Kandang Limun, Kota
Bengkulu, Ph. +62 736-21170, 21884
Fax-+62 736-22105. Email:
pokjaeqc@unib.ac.id,.
II. INSTRUCTIONS ON PRE-
QUALIFICATION APPLICATION
A. General
1. The Bid Committee will receive
application for the Pre-Qualification
of eligible consultants for the work
package of Equipment Consultant
(EQC) Procurement to support the
Project of Establishment of University
of Bengkulu’s Hospital.
2. The Consultant should have capacity
in providing required professional
staff in number and qualification as
well as supporting facilities to conduct
the work package of Equipment
Consultant (EQC) Procurement to
support Project of The Establishment
of University of Bengkulu‟s Hospital
3. To meet the clausal A.1 and A.2, the
consultants may act as a single firm or
joint venture
B. Submission of Application for Pre-
Qualification
1. Applications for Pre-Qualification
have to be directly submitted or sent
through postal services to the office
of POKJA (Procurement Unit)
University of Bengkulu. Address:
University of Bengkulu, Rectorate
Building, 2nd Floor, Ruang Rapat 1.
Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756
5. Dokumen permohonan pra-kualifikasi
dapat diantar secara langsung atau dikirim
melalui jasa pengiriman ke alamat Kantor
POKJA (Kelompok Kerja) Universitas
Bengkulu, Gedung Rektorat Lantai 2,
Ruang Rapat 1. Jl. W.R.Supratman
Kandang Limun, Kota Bengkulu, Fax-
+62736-22105, dan email
pokjaeqc@unib.ac.id.
II. PETUNJUK UNTUK PERMOHONAN
PRA-KUALIFIKASI
A. Umum
1. POKJA akan menerima permohonan
untuk Pra-Kualifikasi dari konsultan
yang memenuhi syarat untuk Paket
pekerjaan pengadaan konsultan
peralatan untuk mendukung
Pembangunan Rumah Sakit Universitas
Bengkulu.
2. Konsultan harus mempunyai kapasitas
untuk menyediakan staf profesional
yang diperlukan dalam jumlah dan
kualifikasi serta fasilitas pendukung
untuk melaksanakan kegiatan Paket
Pekerjaan Pengadaan konsultan
peralatan Pembangunan Rumah Sakit
Universitas Bengkulu.
3. Untuk memenuhi ketentuan A.1 dan
A.2 tersebut, konsultan dapat bertindak
sebagai satu perusahaan atau bermitra.
B. Pengiriman Surat Permohonan Pra-
Kualifikasi
1. Permohonan Pra-Kualifikasi dapat
disampaikan secara langsung atau
dikirim melalui jasa pengiriman ke
alamat Kantor POKJA (Kelompok
Kerja) Universitas Bengkulu, Gedung
Rektorat Lantai 2, Ruang Rapat 1. Jl.
W.R.Supratman Kandang Limun, Kota
2

Jl. WR. Supratman, Kandang Limun,
Kota Bengkulu, Ph. +62 736-21170,
21884 Fax-+62 736-22105. Email:
pokjaeqc@unib.ac.id, no later than
December 21th, 2021 at 15:00 WIB
(GMT+7) to bidding committee of
the work package of Equipment
Consultant (EQC) Procurement to
support Project of Establishment of
University of Bengkulu‟s Hospital.
Late-submitted pre-qualification
documents will be declined and be
returned promptly.
2. The application documents shall be
submitted in 1 (one) original and 3
(three) copies in sealed envelopes and
they shall be marked
“APPLICATION FOR PRE-
QUALIFICATION” the work
package of Equipment Consultant
(EQC) Procurement for Project of the
Establishment of University of
Bengkulu‟s Hospital. The name and
applicant‟s mailing address are
indicated on envelopes. Late
submitted documents will not be
accepted.
3. Any inquiries should be submitted in
writing either in English or in Bahasa
Indonesia.
4. All the pre-qualification form must
be filled. If necessary, additional
sheets may be attached.
5. Each sheet shall be duly signed and
stamped by the applicant or a person
duly authorized to sign on behalf of
the applicant. The authorized person
shall be indicated by a written power
of attorney accompanying the
application.
6. All documents submitted by the
applicants shall be treated as
“confidential” and will not be
returned.
Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756
Bengkulu, Fax-+62736-22105, dan
email pokjaeqc@unib.ac.id, paling
lambat tanggal 21 Desember 2021,
pukul 15.00 WIB (GMT+7) kepada
Kelompok Kerja (POKJA) Paket
Pekerjaan Pengadaan Konsultan
Peralatan Pembangunan Rumah Sakit
Universitas Bengkulu. Dokumen
permohonan pra-kualifikasi yang
disampaikan melewati batas waktu yang
disebutkan diatas akan ditolak dan akan
dikembalikan segera.
2. Dokumen permohonan harus dikirim 1
(satu) asli dan 3 (tiga) fotokopi dalam
amplop tertutup dan diberi tanda
“PERMOHONAN UNTUK PRA-
KUALIFIKASI” Paket Pekerjaan
Pengadaan Konsultan Peralatan
Pembangunan Rumah Sakit Universitas
Bengkulu”. Nama dan alamat pemohon
harus dicantumkan di amplop.
Dokumen yang terlambat tidak akan
diterima.
3. Semua pertanyaan dapat diajukan
dalam bentuk tertulis dalam bahasa
Inggris atau Bahasa Indonesia.
4. Semua isian dalam formulir pra-
kualifikasi harus diisi. Jika perlu, dapat
dilampiri dengan lembar tambahan.
5. Setiap lembar harus ditanda-tangani
dan dicap oleh pemohon atau orang
yang diberi kuasa untuk menanda-
tangani. Orang yang diberi kuasa ini
harus bisa menunjukan surat kuasa.
6. Semua dokumen yang dimasukkan
akan dinyatakan “rahasia” dan tidak
akan dikembalikan.
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7. The Bid Committee will inform all
applicants the result of their
application through the websites:
www.pmursptn.unib.ac.id, www
.unib.ac.id, www
.lpse.kemdikbud.go.id. The Bid
Committee reserves the right to reject
or accept any request to cancel the
pre-qualification process. The Bid
committee also reserves to decline all
applicant letter without any liability
to the affected applicants or any
obligation to inform the background
of rejection to applicant for the
bidding of Equipment Consultant
(EQC) Procurement for Project of
Establishment of University of
Bengkulu‟s Hospital.
C. Pre-Qualification Forms
1. The Pre-Qualification Forms contain
10 (ten) forms as follow :
Form I Letter of Application
Form II General Information
Form III Legal Administration Data
Form IV Financial Data
Form V Professional staff &
General Support Staff of
The Project
Form VI Facilities of the Company
Form VII Experience Data
Form VIII Proposed Project
Organization
Form IX Association Data (only to
be completed by the
company who build an
association)
Form X Integrity Pact
2. An Joint Venture firm must complete
a separate full set of forms for each
partner, Form IX “Association Data”.
A copy of the Association Agreement
must be attached to Form IX. In case
the Association Agreement is not
acceptable to Bid Committee, the
Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756
7. POKJA akan mengumumkan hasil
evaluasi dokumen prakualifikasi
melalui laman www
.pmursptn.unib.ac.id, www .unib.ac.id,
www .lpse.kemdikbud.go.id. POKJA
mempunyai hak penuh untuk menolak
ataupun menerima semua permohonan
untuk membatalkan proses Pra-
Kualifikasi. POKJA berhak menolak
semua surat pemohon tanpa
menimbulkan tanggung jawab apa pun
kepada pemohon atau kewajiban untuk
menginformasikan dasar penolakan
kepada pemohon atas penawaran Paket
Pekerjaan Pengadaan Konsultan
Peralatan Pembangunan Rumah Sakit
Universitas Bengkulu.
C. Formulir Pra-Kualifikasi
1. Formulir Pra-Kualifikasi terdiri dari 10
(sepuluh) formulir sebagai berikut :
Formulir I Surat Permohonan
Formulir II Informasi Umum
Formulir III Data Administrasi Hukum
Formulir IV Data Keuangan
Formulir V Staf Profesional & Staf
Pendukung Umum Proyek
Formulir VI Fasilitas-fasilitas
Perusahaan
Formulir VII Data Pengalaman
Perusahaan
Formulir VIII Organisasi Proyek yang
diajukan
Formulir IX Data asosiasi/kemitraan
(hanya perlu dilengkapi
oleh perusahaan yang
membuat asosiasi)
Formulir X Pakta Integritas
2. Perusahaan kemitraan/ gabungan harus
mengisi formulir IX “data kerjasama”
yang disajikan terpisah oleh masing-
masing mitra di formulir IX “Data
Kerjasama”. Salinan dari kesepakatan
kemitraan ini harus dilampirkan pada
Formulir IX. Apabila kesepakatan
4

association may be requested to
modify the agreement accordingly.
3. If necessary, additional sheets may be
added to the forms. Each page of each
form should be clearly marked on the
upper right corner as follows: Form 1,
page 1; Form 2, page 2; Form 3, page
3; and so on.
4. Some of the forms will require
attachments. Such attachments should
be cleary marked as follows:
Attachment 1 to Form 1, Attachment
2 to Form 2 and so on.
D. Evaluation of Application for Pre-
Qualification
1. The Bid Committee will determine the
eligibility of each applicant to
participate in the consultancy services
being financed by the SFD. The
selected applicants will be proposed to
SFD for approval.
2. The group factors: experience;
financial capacity and technical
capability; the experience and
qualification of the professional staff
(Medical and Non-Medical
Equipment Expert, Research
Laboratory Equipment Expert and
IT Expert) will be compared with
requirements. In order to pass the
Pre-Qualification, the applicant must
at least achieve the minimum scores
from each group.
The Pre-Qualification Evaluation in
detail are, The Company must:
a. Has Certificate of Non-
Construction Business Entity (aka
SBU) with a valid education sub-
field (specifically for domestic
applicants).
b. Has legal deed of establishment of
Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756
kemitraan ini tidak dapat diterima oleh
POKJA, perusahaan dapat diminta
untuk memperbaiki kesepakatan ini.
3. Jika diperlukan, boleh menambahkan
lembar tambahan. Setiap halaman harus
diberi tanda dengan jelas disudut kanan
atas sebagai berikut: Formulir 1,
halaman 1; Formulir 2, halaman 2;
Formulir 3, halaman 3; dan seterusnya.
4. Beberapa formulir perlu dilengkapi
dengan lampiran-lampiran. Lampiran
ini harus diberi tanda dengan jelas:
Lampiran 1 untuk Formulir 1, Lampiran
2 untuk Formulir 2, dan seterusnya.
D. Evaluasi untuk Permohonan Pra-
Kualifikasi
1. POKJA akan menentukan kelayakan
masing-masing pemohon untuk turut
serta dalam pengadaan jasa konsultansi
yang dibiayai oleh SFD. Pemohon yang
terpilih akan diajukan untuk
mendapatkan persetujuan dari SFD.
2. Faktor kelompok: pengalaman,
kemampuan keuangan dan kemampuan
teknis jumlah pengalaman dan kualifikasi
dari staf yang akan direkrut (ahli
Peralatan Medis dan Non-Medis, Ahli
Peralatan Laboratorium Penelitian dan
Ahli IT) akan dibandingkan dengan
persyaratan yang dibutuhkan. Agar lulus
Pra-Kualifikasi, pemohon paling tidak
harus mencapai nilai minimum dari
setiap faktor kelompok.
Penilaian Pra-Kualifikasi secara detail
dituangkan dalam formulir isian,
Perusahaan harus:
a. Memiliki Sertifikat Badan Usaha
(SBU) non konstruksi dengan sub
bidang pendidikan yang masih
berlaku (khusus untuk penyedia jasa
domestik)
b. Memiliki Akta Pendirian Badan
5

Business Entities
c. Has a list of professional experts
corresponding to the requirement
d. Legally is not under any lawsuit in
court and is not bankrupt.
e. Legally is eligible to sign the
contract according to law
regulation.
f. Has settled all taxes for the last
year (annual notification letter).
g. Have financial reports that have
been audited by a Public
Accounting Firm (AKA/KAP) with
an opinion of either "Qualified
(AKA/WTP)" or "Unqualified
(AKA /WDP)".
h. Has contract during the last 10
(ten) years (2011 to 2020) and has
experience as consultant or sub-
consultant or partner in a venture.
i. Has the excellent reputation and is
not included in the black-list of the
government institution.
j. Provide experts and specialists as
required
k. The Firm must declare that all
statements are complete, accurate
and correct.
3. An applicant‟s financial capacity will
be evaluated based on net value,
working capital, and the value of the
unfinished portion of current
contracts.
4. In case of discrepancies and
differences found in the information
submitted, the applicant is not eligible
to bid, and the applicant will be
eliminated from the participation in
bidding process.
5. The decision of the Bid Committee of
EQC Procurement for Project of the
Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756
Usaha atau perubahannya
c. Memiliki Tenaga Ahli sesuai dengan
persyaratan yang dibutuhkan
d. Tidak sedang dalam tuntutan
pengadilan dan tidak bangkrut.
e. Secara hukum mempunyai kapasitas
menandatangani kontrak sesuai
dengan ketentuan yang berlaku.
f. Telah memenuhi kewajiban
perpajakan tahun pajak terakhir (SPT
Tahunan).
g. Memiliki laporan keuangan yang telah
diaudit oleh Kantor Akuntan Publik
(KAP) dengan opini “Wajar Dengan
Pengecualian (WDP)” atau “Wajar
Tanpa Pengecualian (WTP)”.
h. Memiliki kontrak selama 10 (sepuluh)
tahun terakhir (sejak tahun 2011 s.d
2020) dan memiliki pengalaman
dalam jasa konsultansi termasuk
pengalaman sub-konsultansi atau
mitra.
i. Memiliki reputasi yang baik dan tidak
termasuk dalam daftar hitam instansi
pemerintah.
j. Mampu menyediakan tenaga ahli dan
spesialis yang diperlukan.
k. Perusahaan harus menyatakan bahwa
seluruh pernyataan yang dibuat adalah
lengkap, tepat dan benar.
3. Kemampuan keuangan pemohon akan
dinilai atas dasar nilai netto, modal kerja
dan nilai bagian pekerjaan yang belum
selesai dari kontrak yang sedang
berjalan.
4. Apabila dalam pernyataan yang dibuat,
terdapat perbedaan, ketidakcocokan
dalam informasi yang disampaikan,
maka pemohon tidak berhak turut serta
dalam proses pelelangan
5. Keputusan POKJA Paket Pekerjaan
Pengadaan Konsultan Peralatan
6
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Establishment of University of Pembangunan Rumah Sakit Universitas

Bengkulu’s Hospital will be final and Bengkulu adalah final dan tidak dapat
inviolable. diganggu gugat.

7
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Pre-Qualification Form/
Formulir Pra-Kualifikasi

Form I / Formulir I

8
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

A. FORM I - LETTER OF APPLICATION /

FORMULIR I – SURAT PERMOHONAN

Registered Business Name/ : ……………………………………………………

Nama Perusahaan Terdaftar

Business Address / : ……………………………………………………

Alamat Perusahaan

Telephone / Telepon : ……………….. Facsimile/ Fax ……………….

To/ Kepada : BID COMMITTEE/ KELOMPOK KERJA (POKJA)

Sirs,

1. We hereby apply to be pre-qualified by Bid Committee, as a bidder for Equipment

Consultancy Services for Establishment of University of Bengkulu's Hospital Project /
Bersama ini kami mengajukan permohonan untuk mengikuti pra-kualifikasi yang
dilaksanakan oleh POKJA sebagai peserta pengadaan untuk Paket Pekerjaan Pengadaan
Konsultan Peralatan Pembangunan Rumah Sakit Universitas Bengkulu.

2. We authorize ……………………………………………*) or its authorized representatives

to conduct any investigations to verify the statements, documents and information submitted
and to clarify the financial and technical aspects of this application. For this purpose, we
hereby authorize …………………………………………... *) or any other person or firm to
furnish pertinent information deemed necessary and requested by Bid Committee to verify
statements and information provided in application or regarding our competence and
position/ Kami memberi kuasa kepada ……………………………………………..*) ataupun wakilnya
yang diberi kuasa untuk melakukan investigasi/ memeriksa/ menguji pernyataan-pernyataan,
dokumen-dokumen dan informasi yang diberikan dan mengklarifikasi aspek keuangan dan teknis dari
permohonan ini. Untuk keperluan ini kami dengan ini memberikan kuasa penuh kepada
……………………………………....*) ataupun orang lain atau perusahaan lain untuk memberikan
keterangan yang berhubungan dengan persoalan ini yang dianggap perlu ataupun diminta oleh
Panitia Pengadaan untuk memeriksa/ menguji pernyataan dan informasi yang diberikan dalam
permohonan ini atau mengenai kompetensi dan kedudukan kami.

3. The names and position of persons who may be contacted for further information, if required,
are the Executive Director or the authorized representatives as follows:/ Nama dan jabatan
orang-orang yang bisa dihubungi untuk mendapatkan keterangan lebih lanjut, apabila diperlukan,
adalah Direktur Eksekutif atau wakil-wakilnya yang diberi kuasa sebagai berikut :

(a) Technical/ Teknis : ……………………………………………………

(b) Financial/ Finansial : ……………………………………………………

(c) Personnel/ SDM : ……………………………………………………

9
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

4. We declare that the statements made and the information provided in duly completed
application are complete, true and correct in every detail./ Kami menyatakan bahwa peryataan
yang dibuat dan keterangan yang diberikan dalam permohonan ini diberikan dengan baik, lengkap,
betul dan benar dalam segala hal.

Respectfully, / Hormat kami,

Stamp
Rp. 10.000,-

(Applicant)/
Pemohon
Date / Tanggal : ………………………

Form II/ Formulir II

10
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

B. FORM II– GENERAL INFORMATION /

FORMULIR II - INFORMASI UMUM

Company Name/ Nama Perusahaan : …………………………………………………

1. Head Office Address / Alamat Kantor Pusat : ………………………………………

Telephone/ Telepon : …………………… Facsimile/ Fax : …………………………

2. Regional Office Address (if any) / : ………………………………………

Alamat Kantor di Daerah (Jika ada)

Telephone/ Telepon : …………………… Facsimile/ Fax : ………………………

3. Local Office Address (if any) / : ………………………………………

Alamat Kantor Cabang (Jika ada)

Telephone/ Telepon : …………………… Facsimile/ Fax : ………………………

4. Country and Year Incorporated1 :

/ Negara dan tahun Perusahaan didirikan

………………………………………………………………………………………..
………………………………………………………………………………………..

5. Main Lines of Business/ Bidang usaha utama :

………………………………………………………………………………………..
………………………………………………………………………………………..

1. ……………………………. Since/ Sejak: …………………………

2. ……………………………. Since/ Sejak: …………………………
3. ……………………………. Since/ Sejak: …………………………
4. ……………………………. Since/ Sejak: …………………………

1
Attach copy of certificate of registration and ownership/ Lampirkan fotokopi sertifikat registrasi dan kepemilikan.

11
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Form III/ Formulir III

C. FORM III – LEGAL ADMINISTRATION DATA/

FORMULIR III - DATA ADMINISTRASI HUKUM

Eligible Consultant who is interested to attend the Pre-Qualification bidding should attach the
copies of company‟s legal administration data, as follows/ Konsultan yang memenuhi syarat yang
berminat mengikuti penawaran Pra-Kualifikasi harus melampirkan fotokopi data administrasi hukum
perusahaan, sebagai berikut :

1. Business Qualification Certificate/

Sertifikasi Kualifikasi Perusahaan

2. Tax Registration Number/

NPWP (Nomor Pokok Wajib Pajak)

3. Business Certificate of Consultancy Service License /

IUJK (Izin Usaha Jasa Konsultansi )

4. Legal Firm Establishment and Its Changes/

Akta Notaris Pendirian Perusahaan Dan Perubahannya

5. Firm‟s Audited Balance Sheet /

Neraca Perusahaan yang telah diaudit

6. List of Company‟s Chief Executive Officer /

Daftar Nama Pimpinan Perusahaan

7. List of Company‟s Shareholders /

Daftar Nama Pemegang Saham Perusahaan

8. List of Firm Experiences /

Daftar Pengalaman Perusahaan

9. Membership of National Association of Indonesian Consultants (NAIC)

(Tanda Anggota Assosiasi Konsultan Indonesia)

10. Has settled all taxes for the last year (annual notification letter)/
Telah memenuhi kewajiban perpajakan tahun pajak terakhir (SPT Tahunan)

Form IV / Formulir IV

D. FORM IV– FINANCIAL DATA /

FORMULIR IV - DATA FINANSIAL

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 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

A. Summary of assets and liabilities on the basis of the audited financial statement 2 of the
last 3 (three) financial years 2018, 2019 and 2020/ Ringkasan dari kepemilikan dan kewajiban
atas neraca keuangan yang telah diaudit2 pada tahun anggaran 2018, 2019, 2020.

Description Year 2018 Year 2019 Year 2020

1. Total Assets/ Jumlah Aset

2. Current Assets/ Aset Lancar

3. Total Liabilities/ Total Kewajiban

4. Current Liabilities/ Hutang Lancar

5. Net Value (1-3)/ Nilai Keseluruhan

6. Working Capital (1-2)/ Modal Kerja

B. The existing commercial bank that provides credit, (if any)/

Bank komersial yang memberikan kredit, (jika ada)
1. Name/ address of commercial bank that providing credit /
Nama/ Alamat Bank Komersial yang menyediakan kredit

………………………………………………………………………………………..
………………………………………………………………………………………..

2. The total amount of current credit/

Jumlah Kredit yang berjalan

………………………………………………………………………………………..
………………………………………………………………………………………..

Form IV/ Formulir IV

3. List of all on-going contracts3/ Daftar seluruh kontrak yang sedang berjalan

2
Attach copies of the audited financial statements by public accounting of the last 3 (three) years/ Lampirkan fotokopi dari
Neraca Keuangan yang telah diaudit* pada 3 (tiga) tahun terakhir
3
Attach copies of the contracts/ Lampirkan salinan kontrak

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 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Value of Work to Completion Date/

Name of Contract Name of
be Completed/ Nilai Tanggal
Contract/ Nama Value/ Nilai Owner/ Nama
Pekerjaan yang masih Penyelesaian
Kontrak Kontrak Pemilik
harus diselesaikan Pekerjaan

STATEMENT/ PERNYATAAN

If in the future, the information provided is not true and correct, we are willing to take all the
consequences due to the rejection from the selection process/ Apabila dikemudian hari, keterangan
yang diberikan ternyata tidak benar dan tidak betul, kami bersedia menerima segala konsekuensinya
berkenaan dengan penolakan pada proses pemilihan.

Respectfully, / Hormat kami,

Stamp
Rp. 10.000,-

(Applicant)/
(Pemohon)

14
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756
Form V/ Formulir V
(*)
E. FORM V - PROFESSIONAL STAFF & SUPPORTING PROFESSIONAL STAFF
FORMULIR V - STAF PROFESIONAL & PENDUKUNG STAF PROFESIONAL

Project Employment
Education Responsibility/ Status/ Status
Ref.No. of Professional Experience
Date of Birth/ Background/ Latar Tanggungjawab Experience/ Kepegawaian
No Name/ Nama Certificate/ (Years/ Tahun)/
Tgl Lahir Belakang Proyek Pengalaman (Permanent/ Part
No. Ijazah Pengalaman Kerja
Pendidikan time)/ (Tetap/
Paruh waktu)

(*)
Expertise as requested in Appendix 1/ Keahlian seperti yang diminta dalam Lampiran 1

Respectfully, / Hormat kami,

(Applicant)
(Pemohon)

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 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Form VI/ Formulir VI

E. FORM VI – FACILITIES OF THE FIRM /

FORMULIR VI - FASILITAS-FASILITAS PERUSAHAAN

No Name of Equipment/ Nama Barang Amount/ Jumlah (unit) Specifications/ Spesifikasi

Respectfully, / Hormat kami,

(Applicant)
(Pemohon)

16
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Form VII/ Formulir VII

F. FORM VII – EXPERIENCE DATA /

FORMULIR VII - DATA PENGALAMAN PEKERJAAN

1. Total number of years of experience in Equipment consultancy services/ Jumlah tahun pengalaman pada jasa
konsultansi peralatan

Nature of Work/ Jenis Pekerjaan Number of Years of Experience/ Jumlah Tahun Pengalaman

(i)

(ii)

(iii)

(iv)

(v)

(vi)

(vii)

17
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Form VII/ Formulir VII

2. List of all loan-funded projects at value of equivalent or above US$ 150,000 executed during the last five years that similar in nature to the
contract for which this application is made. *)Every project in this table must be attached with detailed information in Description of
Assignment (see page 19) and copies of the contract agreement must be attached/ Daftar semua proyek yang dananya berasal dari pinjaman
dengan nilai setara US $ 150.000 atau lebih yang dilakukan selama lima tahun terakhir yang serupa terhadap jenis kontrak untuk permohonan ini
dibuat. *) Setiap proyek dalam tabel ini harus dilampirkan dengan informasi rinci dalam Deskripsi Penugasan (lihat halaman 19) dan fotokopi
perjanjian kontrak harus dilampirkan.

Position (Lead or Value(4) for Which Contract

Association or Consultant was Period Name of
Title of Agency and Loan Country/
sub-contract)/ Total Value(4) responsible(5) (months) Start Client/
Project/ Credit Number/ Negara
Kedudukan / Jumlah Nilai /Nilai (4)/yang menjadi – Completion / Nama
Nama Proyek Pemberi dan
(Utama atau tanggung jawab Waktu Kontrak Pemberi
Nomor Pinjaman
kerjasama atau konsultan(5) (bulan) Mulai- Kerja
Sub-kontrak) Selesai
1.

2.

3.

4.
..
n.

18
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

3. List of all non-loan funded projects value of US$ 250,000 equivalent or above executed during the last five years similar in nature
to the contract for which this application is made. *) Every project in this table must be attached with detailed information in
Description of Assignment (See page 19) and copies of the contract agreement must be attached.
Daftar semua proyek yang dananya berasal bukan dari pinjaman dengan nilai setara US $ 250.000 atau lebih dilakukan selama lima tahun
terakhir yang serupa terhadap jenis kontrak untuk permohonan ini dibuat. *) Setiap proyek dalam tabel ini harus dilampirkan dengan
informasi rinci dalam Deskripsi Penugasan (Lihat halaman 19) dan fotokopi perjanjian kontrak harus dilampirkan.

Position (Lead or Value (4) for Which Contract

4
Title of Association or Total Value Consultant was Period Name of Country/
Project / sub-contract)/ / Jumlah Nilai responsible5 (months) Start Client/ Negara
Source of Fund /
Nama Proyek Kedudukan /Nilai (4)/yang menjadi – Completion / Nama
Sumber Dana
(Utama atau tanggung jawab Waktu Kontrak Pemberi
kerjasama atau konsultan(5) dari Mulai- Kerja
Sub-kontrak) Selesai

1.
2.
3.
...
n.

4
Value in US dollar using exchange rate prevailing on date of contract award/ nilai dalam US$ mengunakan nilai tukar yang berlaku pada tanggal kontrak ditandatangani
5
In case applicant participated as a sub-contract or a partner in a joint venture/ dalam hal permohonan ikut serta sebagai sub-kontrak atau patner dalam sebuah pekerjaan

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 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Form VII / Formulir VII

Attachment for the tables above (see Pages 16,17 and 18)

Description of Assignment

Assignment Name : Approximate Value of The Contract:

(a)
Loan/ Credit Name and Number: Contract number :

Agency :
Country:
Name of Client : Duration of Assignment (Months):

Start Date (Month/Year) : Completion Date (Month/Year):

Position: Approx. Value services provided by your

Director of Firm/Associate/Subconsultant: firm:

In USD:
Name of Firm Director: Total No. of Key Staff Months Provided

Name of Associate (if any): Name of Team Leader:

Relevant Expertise provided for the Service:

Expertise Man
No. Name Main Task
Provided Month

Description of Services:

(a)
If non-loan please fill with “Non-Loan”, if loan please fill with the information
Attach copies of the contracts/ Lampirkan fotokopi kontrak

20
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Form VIII / Formulir VIII

G. FORM VIII – PROPOSED ORGANIZATION/

FORMULIR VIII - STRUKTUR ORGANISASI YANG DIUSULKAN

A. Preliminary Project organization chart including central and local project offices/
Skema organisasi proyek termasuk kantor pusat dan kantor daerah

B. Narrative of project organization chart / Uraian skema organisasi proyek

C. Description of relationship between central and local project offices (indicate clearly
which responsibility and what authority will be delegated to local project office)/
Penjelasan hubungan antara kantor pusat dan kantor daerah (Tulis dengan jelas tanggung jawab
mana dan otorita apa yang akan dilimpahkan kepada kantor daerah).

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 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Form IX/ Formulir IX

H. FORM IX – ASSOCIATION DATA /

FORMULIR IX - DATA KERJASAMA

1. Name(s)/ Nama : ……………………………………….

2. Head Office Address/ : ……………………………………….

Alamat Kantor

Telephone No. : ……………………………………….

Facsimile/Fax No. : ……………………………………….

3. Local Office Address (if any)/ : ……………………………………….

Alamat Kantor Lokal (Jika
ada)

Telephone No. : ……………………………………….

Facsimile/ Fax No. : ……………………………………….

4. Names of Associate6/ :
Nama-nama kerjasama

4.1
.
4.2
.

6
Details about partner to be provided on separate sheets / Penjelasan terperinci mengenai kerjasama hendaknya dicantumkan
pada halaman lain

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 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Form IX/ Formulir IX

5. Name(s) of Lead Partner (if any)/ :

Nama-nama Mitra Utama (jika ada)

a. …………………………………………..
b. …………………………………………..

6. Association Agreement /
Perjanjian Kerjasama

a. Date of Agreement/ : ……………………………………….

Tanggal Perjanjian

b. Place / Tempat : ……………………………………….

7. Proposed Distribution of Responsibilities Between Partners/

Usulan Pembagian Tanggungjawab antar mitra

23
 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Form X/ Formulir X

I. FORM X– INTEGRITY PACT/

FORMULIR X - PAKTA INTEGRITAS

PAKTA INTEGRITAS/INTEGRITY PACT

Saya yang bertanda tangan dibawah ini / I am who signed the form

1. Nama/Name :

2. Jabatan/Position :

3. Nama Perusahaan/Company :

4. Alamat Perusahaan /Company Adress :

Dalam rangka Paket Pekerjaan Pengadaan Konsultan Peralatan Pembangunan Rumah Sakit
Universitas Bengkulu (Establishment of University of Bengkulu's Hospital Project) di
Universitas Bengkulu Kementerian Pendidikan, Kebudayaan, Riset dan Teknologi dengan ini
menyatakan bahwa saya (In line with the work package of Procurement of Equipment Consultant
(EQC) for the project of Establishment of University of Bengkulu's Hospital Project) in
University of Bengkulu, Ministry of Education, Culture, Research and Technology, I stated that I
1. Tidak akan melakukan komunikasi yang mengarah kepada Kolusi, Korupsi, dan
Nepotisme (KKN) (will not open communication that tend to Collusion, Corruption, and
Nepotism)
2. Tidak akan melakukan praktik Korupsi, Kolusi dan Nepotisme (KKN) (will not commit
to Collusion, Corruption, and Nepotism at any way)
3. Akan melaporkan kepada pihak yang berwajib/berwenang apabila mengetahui ada
indikasi Korupsi, Kolusi dan Nepotisme (KKN); (will report to the authority if there is
indication of Collusion, Corruption, and Nepotism)
4. Bersedia diaudit oleh Auditor independen. (will be available to be audited by
Independent Auditor)
5. Tidak memberi sesuatu yang berkaitan dengan Paket Pekerjaan Pengadaan Konsultan
Peralatan Pembangunan Rumah Sakit Universitas Bengkulu (Establishment of University
of Bengkulu's Hospital Project) yang dapat dikategorikan sebagai suap atau gratifikasi.
(will not give everything related to the work package of Procurement of Equipment
Consultant (EQC) for the project of Establishment of University of Bengkulu's) which is
categorized as brive or gratification.

Apabila saya melanggar hal-hal yang telah saya nyatakan dalam PAKTA INTEGRITAS ini, saya
bersedia dikenakan sanksi sesuai dengan ketentuan perundang – undangan (in case if I violate the

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 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

commitment that I stated in INTEGRITY PACT, I am willing to be sanctioned corresponding to

the law).

……., …………….. … 2021

Signature

Stamp Rp.10.000

(Applicant)
(Pemohon)

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 Short Listing / Pre-Qualification Document
Equipment Consultant (EQC)
Establishment of University of Bengkulu's Hospital Project
SFD LOAN NO. 12/756

Appendix 1: Professional Staff & Supporting

Professional Staff
The estimated number of key experts and supporting staff required:

No Expertise Number of Experience

personnel
A. Professional Staffs
1 Team Leader 1 A Master degree or Equivalence in
Electrical/Mechanical/Physical Engineering or
Biology or Chemistry or Health/Medical with
at least 4 years of experience in Project
Management, preferably having experience in
medical education center and research center
equipment or bachelor degree in
Electrical/Mechanical/Physical Engineering or
Biology or Chemistry or Health/Medical with
at least 8 years of experience in Project
Management
2 Medical and Non-Medical Equipment 1 at least 4 years experiences
Expert
3 Research Laboratory Equipment Expert 1 at least 4 years experiences
4 IT Expert 1 at least 4 years experiences
B. Subprofessional Staffs
1 Junior Field Equipment Supervisor 1 at least 3 years experiences
2 Junior IT Equipment Expert 1 at least 3 years experiences
C. Supporting Staff
1 Bilingual Secretary 1 at least 3 years experiences
2 Driver 1 at least 3 years experiences
3 Office Boy/Courier 1 at least 3 years experiences

26