VENDOR REGISTRATION FOR INFOPATH

X New Update ________________

Requesting Office: I.D. NO:

Vendor Name (Company Name): PT. Grogol Sarana Transjaya

Vendor Legal Name: PT. Grogol Sarana Transjaya

UNGM No. (If any)

Tax I.D. No: 01.979.270.4-631.000

Commodity Type: Container Handling, Container Lift Part Equipment, Heavy Equipment Rental, Terminal Operator, Transportation

Address: Jl. Tanjung Priok Indah Permai 29/F-6 Surabaya

Street Jl. Tanjung Priok Indah Permai 29/F-6 Surabaya, Kelurahan Perak Barat, Kecamatan Krembangan, Kota Surabaya

City: Surabaya State/Province: East Java

Postal Code: 60186 Country: Indonesia
+62 21 43988661 - 663
Telephone No: +62 81280153131
Fax No: (+62 31) 499310-309

E-mail Address:
dion@emitraco.com
(the e-mail provide in the fund transfer pemasaran@emitraco.com Website: http://www.emitraco.com/www.grogol.co.id
form has to be included)

Contact Person Detail

First Name - Last Name Gideon

Email Address: dion@emitraco.com / pemasaran@emitraco.com

Phone Number: +62 8119358877

Primary Bank Detail

Payment Method TRANSFER

Bank Country INDONESIA

Bank Name BANK MANDIRI

Bank Account Number 140-000-581-4000

Bank Account Name PT GROGOL SARANA TRANSJAYA

Bank SWIFT or IBAN (if any) BMRIIDJA

Bank Location ID
CABANG SURABAYA PELABUHAN TANJUNG PERAK
(Local or International)

REQUESTED BY: EXTENSION:

SIGNATURE: DATE:

PLEASE FORWARD THE COMPLETED FORM TO: Procurement Unit (PU)

(Please type or print, and return the completed Excel format) Emaill address: verawan.phatrathamrongchai@un.org