BUSINESS PARTNER DATA FORM

Business Partner Data

Company Name : KOPERASI KARYAWAN USAHA SEJAHTERA BERSAMA
Business Entity : ( ) Limited Liability Company ( ) Other: Koperasi
Registered Address : Ruko Kartini Megah Blok A3, Jl. RA. Kartini 150-152, Gresik

Shipping Address : Ruko Kartini Megah Blok A3, Jl RA. Kartini 150-152, Gresik
(if different with registered address)
Telephone No. : 031-3987835 Facsimile :
Contact Person : Mufid Santoso Email : mufid@kkusb.com
Number of Deed after adjusted : Click here to enter text. Date :
to Law No. 40/2007 *) Notary : Keputusan Menteri Koperasi & Pembinan Pengusaha Kecil
Decree No.: 216/BH/KWK.13/III.1997 Date : 31 Maret 1997
Number of Deed of the latest : Date:
changes of BoD/BoC *) Notary : Sulikarmiati, S.H.,M.Kn.
Decree No.: 05 Date : 14 Juni 2021
Company Registration Certificate No.*): 0220002190834 Date of Expiration : Click here to
Certificate of Domicile No.*) : 503/36/437.102.16/2023 Date of Expiration: 17 Juli 2023
Trade Business License No. *) : Click here to enter text. Date of Expiration: Click here to
Tax Payer Registration No.*) : 01.721.971.8-641.000
Taxable Entrepreneur Confirmation Click here to enter text.
Letter No.*) :
Financial Report *) **) : Period : 2022 Omset Tahunan : 76.706.396.575
Authorized Capital: Click here to enter Paid Capital :
text.
Majority Shareholder/:
Parent Company Total : % of share

PIC
Title Name Email Signature Specimen
Director YUDI HARSONO Click here to enter text. Click here to enter te
Click here to enter text.
Head of Finance ERVA DWI MULYATI Click here to enter text. Click here to enter te
Department Click here to enter text.
Head of Purchasing MUFID SANTOSO Click here to enter text.
Department Click here to enter te

*)document to be attached.
**) In the event Bussines Partner could not provide the Financial Report, Balance Sheet (in separated form) should be co
by Business Partner.

Business Partner hereby confirm that all information provided here are accurate and true and indemnify the receiving pa
all the damages caused by inaccuracy and untrue information given by Business Partner. Business Partner should inform
information changes (if any) by attaching the new Business Partner Data Form and the changing document within 30 cale
after the effective date of the changes.

Name :
Title :
Date :
Signature and Company Stamp :
CTI Group – 16 to be printed on A4
CTI Group – 16 to be printed on A4