New Customer Application Form

PT. Wahana Boga Nusantara

We would like to express our gratitude for the trust and opportunity to us PT. Wahana Boga Nusantara as one of
your supplier.
Please to fill in the application form and attach additional information needed as the requirement to be PT. Wahana
Boga Nusantara‘s member.
By submitting back the application form, all “terms and conditions” are agreed and accepted.

1. Company Name (PT/CV/UD):______________________________________________________________________

Bussiness name ( Outlet Name ): __________________________________________________________________

SHRIMPIS Restaurant

2. Phone Number: ____________________________________

(0361) 9344039 ; Fax: _____________________________________

3. Delivery Address ( Phone Number ): ______________________________________________________________

Jl. Petitenget No. 4, Seminyak, Bali (across Pantai Petitenget)

___________________________________________________________________________________________________

Jl. Petitenget No. 4, Seminyak, Bali (across Pantai Petitenget)

Billing Address: ________________________________________________________________________________

___________________________________________________________________________________________________

4. Company Name as on NPWP: _______________________________________________________________________

Suryajaya Kencana Wangsa
Jl. Nangka Selatan GG. Nuri I No 25 C, Dangin Puri Kaja,
5. Company Address as on NPWP: _____________________________________________________________________
Denpasar Utara, Denpasar Bali
______________________________________________________________________________________________________

6. Billing Information:

 Bank Name & Bank Address : ________________________________________________________________

Bank Central Asia

 Lusia Megaria Tantra

Name of Acc Holder: _______________________________________________________________________

 Account Number Bank – SWIFT Code: ___________________________________________________________

0403064413

7. Other Suppliers with credit payment facility:

Supplier Contact & Phone number Terms Of Payment

0859-5377-9090 30 days credit

SAI Fresh Vegetables
(Monthly)

30 days credit
IXORA Cake 0851-0020-06999
(Monthly)

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PT. WAHANA BOGA NUSANTARA
Lotus Enterprise Building, Jl. Bypass Ngurah Rai No. 18, Jimbaran, Bali 80361, Indonesia
Tel. 62 -361 701650 ; Fax. 62 361 701007 ;Email: salesfoodbali@lotusfoodservices.co.id or sales.retail@lotusfoodservices.co.id
 8. Contact of Person In Charge (Scratch the unnecessary):

Name Position Email Address Mobile Phone

Owner
Suryajaya Kencana 0811-3881-285
Wangsa ( Mandatory )

General Manager /
Director

Executive Chef
Rashita Lakshan
Ailapperuma 0878-5069-6008

F&B Director

Purchasing
Manager / Officer

Financial Controller

AP Officer

Other:

9. Monthly Purchase Estimation (Rp.):___________________ ________________________________________________________________

10. Billing payment agreed by two parties:

10.1. First 3-Months : ___________________ s/d _________________________: COD (Cash).

10.2. Second 3-Months : _____________________ s/d _______________________: 15-days credit purchase from purchase
fromdate 1st to15th will be paid on date25th same month; Purchase from date 16 th to 30th /31st will be paid on
the 10th next month.

10.3. 7th Month forward: 30 – days Credit,the purchase from date 1st to 30th/ 31st will be paid on 20th next month.
10.4. Remarks: _______________________________________________________________________________________________

_______________________________________________________________________________________________________

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PT. WAHANA BOGA NUSANTARA
Lotus Enterprise Building, Jl. Bypass Ngurah Rai No. 18, Jimbaran, Bali 80361, Indonesia
Tel. 62 -361 701650 ; Fax. 62 361 701007 ;Email: salesfoodbali@lotusfoodservices.co.id or sales.retail@lotusfoodservices.co.id
 SHRIMPIS Restaurant
On behalf of the company ___________________________________________________________________________

I agree to guarantee the payment on time as agreed on point 10 above.

___________________, _________________________ 2021

Meterai (Stamp) Rp. 6000

Suryajaya Kencana Wangsa

_____________________________________________________________

Position: ____________________________________________________
Owner
SHRIMPIS Restaurant
Company Name _____________________________________________

Completed by Accounting PT. Wahana Boga Nusantara:

Account Application accepted on date: ___________________________________________________________

Proposed by:_________________________________________________________________________________

Approved by:

 Sales Manager: ________________________________ date: _________________________________

 Acct Receivable: ______________________________ date: __________________________________

 Director: _____________________________________ date: __________________________________

Inputted to WBN System date: __________________________________ by: ___________________________

Customer Name in System: ____________________________________________________________________

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PT. WAHANA BOGA NUSANTARA
Lotus Enterprise Building, Jl. Bypass Ngurah Rai No. 18, Jimbaran, Bali 80361, Indonesia
Tel. 62 -361 701650 ; Fax. 62 361 701007 ;Email: salesfoodbali@lotusfoodservices.co.id or sales.retail@lotusfoodservices.co.id
DOCUMENT APPLICATION NEW CUSTOMER
1. Customer / Legal Customer ( PT or CV )
1.1 Surat Keterangan Domisili Perusahaan
1.2 SK Menteri Hum & Ham RI untuk Akta Pendirian & Perubahannya
1.3 Akta Berita Acara Susunan Direksi / Komisaris Terakhir ( Jika ada
perubahan )
1.4 SIUP
1.5 NPWP Perusahaan
1.6 Surat Pengukuhan Pengusaha Kena Pajak
1.7 TDP
1.8 SIUP – MB ( TPE : Tempat Penjual Eceran ) – Mikol
1.9 NPPBKC ( TPE : Tempat Penjual Eceran ) – Mikol
1.10 KTP Direktur & Pemilik / Pemegang Saham (jika Pemegang Saham tidak
sama dengan Direktur)
1.11 Bukti Pembayaran PDAM & PLN 3 Bulan Terakhir

2. Customer Perorangan :
2.1 KTP & NPWP & KK Atas Nama Customer
2.2 Bukti Pembayaran PDAM & PLN 3 Bln Terakhir

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PT. WAHANA BOGA NUSANTARA
Lotus Enterprise Building, Jl. Bypass Ngurah Rai No. 18, Jimbaran, Bali 80361, Indonesia
Tel. 62 -361 701650 ; Fax. 62 361 701007 ;Email: salesfoodbali@lotusfoodservices.co.id or sales.retail@lotusfoodservices.co.id