PT.

KEYENCE INDONESIA
Alamanda Office Tower Unit D, 20th floor Phone +6221-2966-120
Jl. TB. Simatupang Kav.23-24, RT001 RW001 Fax +6221-2966-121
Cilandak Barat, Cilandak, Jakarta Selatan, DKI Jakarta 12430 www.keyence.co.id
CUSTOMER REGISTRATION FORM
Date of Registration : 28-Nov-18

A. COMPANY IDENTITY
1. Company Name : PT. TJOKRO NIPPON ENGINEERING
2. Address : Kawasan Industri Mitra, Jl. Mitra Selatan II, Blok I No.8, Ciampel, Jawa Barat
City : Karawang Postal Code : 41363 Phone : 0267-8636571
3. Nature of Business : Automotive Fax : 0267-8636570
(Manufacturing / OEM / Distributor / Others*)
4. Parent Company Name :
5. Parent Company Nationality :
6. Company Website :

B. BILLING INFORMATION ( If address is different with letter A, please complete Billing address )
1. Company Name :
2. Billing Address :
City : Postal Code : Phone :
3. Invoice receiving schedule : Fax :
4. Invoice payment schedule :

C. SHIPPING INFORMATION ( If address is different with letter A, please complete Shipping address )
1. Company / Factory Name :
2. Shipping Address : Phone :
City : Postal Code : Fax :

D. CONTACT PERSON
1. Main Contact Person Name : Austen Department : PPIC
Phone : Ext. : 101
Mobile Phone : 085711876090 Email :
2. Finance Name : Farisa Department : Finance
Phone : Ext. :
Mobile Phone : Email :
3. Invoice Name : Department :
Phone : Ext. :
Mobile Phone : Email :

I/We certify that the above information is true and correct.

Stamp & Signature

Please submit NPWP, SPPKP, and Tanda Daftar Perusahaan (TDP) together with this form

TO BE FILLED BY KEYENCE'S STAFF Manager Approval

1. Sales Engineer Name :
2. Territory :
3. Customer Payment Term :