CREDIT APPLICATION FORM

NOTE : It is important that this form is completed in full. Insufficient information may result in
unnecessary delay in processing your application. All terms and conditions over leaf are
deemed to be part(s) of this application and have been read, understood and accepted by you
in total at time of your application for credit facilities at ibis Styles Cikarang.
Name of Company or Firm: Nature of Business:
RUMAH SAKIT PERMATA KELUARGA JABABEKA

Address: Phone Number:

Jl. Dr. Cipto Mangukusumo Blok A/1A, Medical City, Kota 021-29083399
Jababeka, Bekasi
Type of Company : PRIVATE / PUBLIC LTD / SOLE PROPRIETOR / PARTNERSHIP

(Delete where not applicable)

Authorized Capital : Paid-Up Capital : No. of Employees :

PARTICULARS OF PERSONS AUTHORIZED TO MAKE HOTEL ARRANGEMENTS,

ISSUE INSTRUCTIONS AND SIGN ON BEHALF OF COMPANY.
Name in BLOCK Position Held ID Card or Passport Signature
CAPITAL Number

1 dr. Merry B, MM Director

2 dr. Wistafia A Ajami Manager

Marketing
3

NOTE : Please notify ibis Styles Cikarang if there are changes or amendments to the
above authorized signatories. If written notification is not received, the above signatories will
still be valid and the company is still liable or all changes incurred thereafter.

Company’s Bankers : Account No :

(Please State Branch)

Register of Company (ROC) No :
Bank Address :

ibis Styles Cikarang

Jl. H. Usmar Ismail, Jababeka II Movieland Kav. 2B, Cikarang Utara, Bekasi 17530, West Java – Indonesia
T : (021) 89 323 300, F : (021) 89 323 900, ibis.com/9196 - accorhotels.com/9196
DO YOU OR YOUR COMPANY PRESENTLY HAVE OR PREVIOUSLY HAD AN ACCOUNT WITH
OTHER HOTELS (If YES, please furnish the following particulars )
Name of Hotel : Address :

1 - -

2 - -

3 - -

The undersigned (an authorized signature) hereby requests that a corporate account be opened at
ibis Styles Cikarang. In connection with the above particulars, the undersigned authorizes the receipt
and exchange of credit information. The company will be liable for all charges incurred at ibis Styles
Cikarang, by the company’s guests unless otherwise instructed in writing. The company will be bound
by the terms and conditions contained over leaf upon approval of the application for credit facilities at
ibis Styles Cikarang.

CREDIT FACILITIES – TERMS AND CONDITIONS

1) These terms and conditions are deemed to best parts(s) of the application for credit facilities at
ibis Styles Cikarang.
2) Granting of credit facilities shall be at the sole discretion of ibis Styles Cikarang.
3) All charges incurred by the company shall be billed to its business address and settlement of
outstanding shall be payable within 14 days upon presentation of the bills.
4) The amount of each bill should be paid excluding of any bank charges and in the currency of the
bill.
5) The company must inform ibis Styles Cikarang if there are any changes / amendments to the
authorized signatories or any other related matters. Prior to the receipt of written notification the
company will still be liable for any charges incurred thereafter.
6) This credit facility is not transferable to other companies, sister companies, or associates
companies of the approved company.
7) For all credit balances which are not cleared within 14 days after receiving the bill, 2 (two) percent
interest per month will be applied and reservation will be treated on cash basis.
8) The hotel reserves the right to withdraw, suspend or increase the credit facilities at any time. Such
notification shall be made in writing to the company informing them of the hotel’s decision without
having to assign any reason whatsoever.
9) The company undertakes to reimburse and to indemnify the hotel for all looses expenses and
damages that have resulted directly or indirectly from the negligence and/or malicious actions of
the company and/or his guests.
10) This present form is valid for 1 year (01 Jan 2022 – 31 Dec 2022)
11) In order for this credit facility to be valid, please return this completed application by facsimile or
email, and we shall reply to your application as soon as possible.

SIGNATURE & COMPANY STAMP :

* Please attach a copy of your passport or identity card for verification.

Name: dr. Merry Berlian, MM Designation :

ibis Styles Cikarang

Jl. H. Usmar Ismail, Jababeka II Movieland Kav. 2B, Cikarang Utara, Bekasi 17530, West Java – Indonesia
T : (021) 89 323 300, F : (021) 89 323 900, ibis.com/9196 - accorhotels.com/9196
 CONTACT PERSON RESPONSIBLE FOR THE PAYMENT

Name : Susanty Lukman Position : Supervisor

Tel. : 021-29083399 Fax. :

E-mail Address : Signature :

Finance-jb@permatakeluarga.net

Mailing Address :

OPERATION MANAGER / handling agent

Name : Wiztafia A Ajami Position : Manager Marketing

Tel : 021-29083399 Fax :

E-mail Address : Signature :
Marketing-jb@permatakeluarga.net
Mailing Address :

Date Approval: Date Expired :

CREDIT AUTHORISATION APPROVAL FORM

Name of Company or Firm:

Recommended by : ( Name & Signature) Position :

Remarks ( if any ) :

Verified by : ( Name & signature ) Position : Credit Manager

Credit Limit Granted :

Director of Sales : Approved / Disapproved

Financial Controller : Approved / Disapproved

General Manager : Approved / Disapproved

ibis Styles Cikarang

Jl. H. Usmar Ismail, Jababeka II Movieland Kav. 2B, Cikarang Utara, Bekasi 17530, West Java – Indonesia
T : (021) 89 323 300, F : (021) 89 323 900, ibis.com/9196 - accorhotels.com/9196