PRF #: 4809-081

Project Name: BGR-CDP

Prepared Date: 09-Sep-22

Waiver

Rationale for Requesting Waiver of Competitive Bidding

Please check the applicable box that explains your reasons for the requested waiver of competitive bidding or for requesting a single/sole
source.

A sole source justification exists if the goods or services required to satisfy are only available from one
Sole Source supplier

An emergency justification may exist if the goods or services are required to: correct or prevent an
emergency health, environmental, or safety hazard; provide for the completion of special or time
Emergency sensitive events; or enable the emergency repair or emergency replacement of existing equipment
essential for daily operations

Sponsor The vendor and items/services requested are specified in the proposal and listed in the award
Designated
agreement. Attach copies of the proposal and award budgets.
Vendor and Item

Others (Please describe)

Name of vendor selected PUSKESMAS SUKAJAYA

Address Jl.Raya Pasir Madang Km 7 Desa Sipayung Kec. Sukajaya Kode Pos 16660

Phone Number 0815 1469 5366

DARWIN NAVIS, SKM, M.K.M
Contact Person

(Local Currency)
Package/others
No. Item Name Item Specification Qty. Unit Price/Unit Total
Qty. Unit

Ggeneral inspection ENT

1 Medical Check Up examination (ear, nose, 832 person 1 times 61,000 50,752,000
throat) and medicine support

2 Transportation for medical Transportation cost 7 times 1 times 500,000 3,500,000

personnel
-
Total 54,252,000
Discount
Tax (PPN 10%) -
Shipping Fee
Grand Total 54,252,000
Term of Payment
Additional Information: Availability/Delivery Time
Others
(i.e after sales services)
Validity Period:
 PRF #:
Project Name:
Prepared Date:

Waiver

Rationale for Requesting Waiver of Competitive Bidding

Please check the applicable box that explains your reasons for the requested waiver of competitive bidding or for req
single/sole source.

A sole source justification exists if the goods or services required to satisfy are only
Sole Source
from one supplier

An emergency justification may exist if the goods or services are required to: correc
an emergency health, environmental, or safety hazard; provide for the completion o
Emergency
X time sensitive events; or enable the emergency repair or emergency replacement o
equipment essential for daily operations

Sponsor
The vendor and items/services requested are specified in the proposal and listed in
Designated
agreement. Attach copies of the proposal and award budgets.
Vendor and Item

Others (Please describe)

Name of vendor selected AIRLANGGA

Address Jl. Danau Toba Raya E1-27 Surabaya

Phone Number 031-716458

Contact Person NOVIA INDRIYANI

Package/others
No. Item Name Item Specification QTY Unit
QTY Unit

1 MASK EARLOOP, 3 PLY 100 Box

Total
Discount
Tax (PPN 10%)
Shipping fee
Grand Total
Term of Payment
Additional Information:
Additional Information: Availability/Delivery Time
Others
(i.e after sales services)
Validity Period: THE PRICE IS VALID UP TO DECEMBER 31, 2021
 PRF #: 4812-001
Project Name: SURABAYA CDP
Prepared Date: Feb 10, 2021

idding

of competitive bidding or for requesting a

ces required to satisfy are only available

services are required to: correct or prevent

rd; provide for the completion of special or
air or emergency replacement of existing

ed in the proposal and listed in the award

d budgets.

GA

E1-27 Surabaya

458

RIYANI

Price/Unit Total

50,000 5,000,000
Rp 5,000,000
Rp -
Rp 500,000 Rp 500,000
Rp 100,000
Rp 5,600,000
BANK TRANSFER, 7 DAYS AFTER
RECEIVING THE INVOICE
AVAILABLE UPON REQUEST/MAR
1, 2021 TO SURABAYA CDP
DELIVERY
OFFICE