PS7-002 REV E_Annexe 2B_22/06/2022

SUBCONTRACTOR’S QUALIFICATION FILE

Creation ☐ Modification ☐ Blocked ☐ Reactivate ☐
N° IFS to specify:...........................................
To be returned within 5 working days to the attention of: Document completed by:
Mr./Mrs. Budianto Date:Sep 29, 2022
Entity: Director
Email: admin@bangkibangunbersama.com Signature ans stamp of the company

OVERALL INFORMATION
Highlighted lines = Mandatories data
Name of the company / Corporate PT. Bangkit Bangun Bersama
Name
Legal status 8120010181471
Creation date November 17, 2018
Head office address (address / postal Jl. Surabaya – Cepu km. 133
code / city / country) Sudu RT.002 RW.003 Kec. Gayam Kab. Bojonegoro (62152) Indonesia
Billing address (if different from
headquarters)
Phone number +6282331426617
Fax
Website www.bangkitbangunbersama.com
DUNS® Code
APE / NAF / NIF code
Registeration number 8120010181471
Intra-community VAT number (if
applicable)
Activity (as coded on the last page) Construction Product
Products / services (attach a brochure) Wellwork Improvement Facilities
Staff
SPIE references Mr. Ma’ruf Amin as an Engineer
(if you have already worked with the
SPIE Group, please specify your
references)
References of your major customers Wellwork Improvement Facilities at Wellpad A and Wellpad C
(specify the type of activity / products
and the year)
Turnover and EBIT of the last 3 years Turnover N-1 : EBIT N-1 :
(K euros) Turnover N-2 : EBIT N-2 :
Turnover N-3 : EBIT N-3 :
Geographic area served (check the Local ☒ Regional ☐ National ☐ International (precise) ☐
appropriate box)

Contact Last name First name Mr. Dede Dwi Jaya

Position Construction Manager
Direct line +6282260909715
E-Mail admin@bangkitbangunbersama.com
Contact QHSSSE Last name First name Agung Tri Sugiharto
Direct line +6281319223434
E-Mail agungtrihse@gmail.com
Contact accountant Last / First name Zainal Abidin
Position Finance & Tax
Direct line +6281357247019
E-Mail abidin@bangkitbangunbersama.com

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PAYMENTS

Method of payment Transfer Bank

Payment terms
Name of the bank Bank Negara Indonesia
Bank address Bojonegoro
Name of the beneficiary PT. Bangkit Bangun Bersama
International Bank Account Number IBAN
SWIFT code / Bank identification code (BIC)
Bank account currency (IDR) 760944169

GROUP / SUBSIDIARY(IES)

If belonging to a Group:

Corporate name of the Group

Head office address (address / postal
code / city / country)
DUNS® Code
Registration number

If holding subsidiary(ies) / branch(es):

Name of the subsidiary

Head office address (address / postal
code / city / country)
DUNS® Code
Registration number

Name of the subsidiary

Head office address (address / postal
code / city / country)
DUNS® Code
Registration number

SHAREHOLDERS OF THE COMPANY/SHARE STRUCTURE

Please specify the names of persons who have a financial Mr. Budianto
interest in the company and complete the following Mr. Indra Yuli Hartono
information Mr. Muhammad Arifin

Mr. Budianto as an President director

Identify the owner of the company holding shares Mr. Indra Yuli Hartono as an director
directly or indirectly through a company Muhammad Nurarifin as an comisaris

45%
If the owner is a corporation, specify the allocation of 22,7%
shares within the corporation 31,8%

Mr. Budianto
If the company is listed, specify the person/entity Mr. Indra Yuli Hartono
holding more than 5% of the share capital Mr. Muhammad Arifin

MANAGEMENT OF THE COMPANY

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Identify the individuals or entities with control over the

management of the business, including the member of
the board of directors or other management structure.
If available, please provide an organizational chart.

List all members of the board (or other management

structure)

Mr Budianto as a President Director

List the names of all General Managers, Vice Presidents
Mr Dede Dwi Jaya as an Site Manager
List the names of all individuals who may hold leadership Mr. Zainal Abidin
positions in the partnership, consortium or joint venture.
Please provide full resumes of these individuals if
applicable
Please specify if there are any public officials or public
corporations listed as managers or shareholders of the
company.

CSR INFORMATION (Corporate Social Responsibility)

Does your company have a CSR policy Yes ☐ No ☒

in place?
Is your company a member of the Yes ☐ No ☒
United Nations Global Compact?
Is your company certified by an Yes ☐ No ☒
international non-financial rating
agency? (e.g. EcoVadis)
If so, by which agency?
Rating
Has your company issued an ethical or Yes ☐ No ☒
CSR code of conduct?
Precise your CSR contact person
Last name First name
Position
Direct line
E-Mail

QSSSE INFORMATIONS

QSSSE Certifications

Domain Specify here the standard / Initial certification date (1st End date of validity of
reference certification with this standard) the last certification
Quality (ISO 9001 or other) ISO 9001 : 2015 August 31, 2015 August 30, 2021
Health, Safety (MASE UIC, ISO OHSAS 18001 : 2007 September 4, 2018 September 3, 2021
14 001, ISO 45001 or other)

Environment (MASE UIC, ISO

14 001, ISO 45001 or other)

Others certifications

 If you are not ISO 9001 certified, please complete the QSSSE questionnaire (appendix 2D) part "information about your
organization in terms of product/service quality"

Information on your environmental impacts

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Question Answer
What are your main environmental impacts?

What actions are you taking to limit them?

INFORMATIONS IN THE CONTEXT OF SUBCONTRACTING

Scope of work:

Geographical area of operation INDONESIA

Language skills French English Others (Specify)

1 in 3 of your employees Indonesian Language
speak
1 in 5 of your employees Indonesian Language
speak
At least 1 person in the team Indonesian Language
speaks

For companies operating in foreign countries:

Have you set up an organisation to assess and ☒ Yes ☐ No ☐ NA If Yes, specify:

control the risks linked to the country (health,
sanitary, security) prior to this type of
mission?
Do you have an insurance policy that allows ☒ Yes ☐ No ☐ NA If Yes, specify:
you to treat or repatriate participants on site?

Employees:

How many staff have you employed over the last 3 years?

Number of people Y-3 Y-2 Y-1

Workforce of the company 7 1 1

Are all staff employed? ☒ YES ☐ NO

Do you have a medical check-up/monitoring? ☒ YES ☐ NO

What insurance have you taken out for Insurance and Social Security (BPJS Ketenagakerjaan)
your employees?

Safety result:
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Items requested Year -1 Year -2 Year -3 Comments

Lost time injury frequency rate

Reference national lost time injury

frequency rate for APE and CTN code
available on
http://www.risquesprofessionnels.ameli.fr/stati
stiques-et-analyse/sinistralite-atmp.html

Frequency rate of reported accidents

(with and without lost time)

Commercial references:

References for similar projects/clients for similar services over the last 3 years:

Project 1 Provision of manpower supply and Client PT. Rekayasa Industri

equipment for Modified Steel
Structure Gas Processing Facilities
and Offsite Area at Jambaran Tiung
Biru Unitization Gas Project

Contact Name Mr. Budianto Contact details

Duration April 13, 2021 – April 30, 2022 Amount 13,000,000,000 IDR

Project 2 Install and Commisioning Client PT. Rekayasa Industri

Sprinkler and indoor hydrant for
receptionis building Jambaran
atTiung Biru Unitization Gas
Project
Contact Name Mr. Budianto Contact details
Duration September 23, 2021`- December Amount 929,946,000 IDR
22, 2021

Project 3 Jambaran Central Minicamp Facility Client PT Pertamina Drilling Service

Construction Services and Shim Indonesia
Substructure Rig Service PDSI# 40.3/
DS 1500-E
Contact Name Mr. Budianto Contact details
Duration April 1, 2020 – December 31, Amount 869,613,192,00 IDR
2020

EVIDENCES TO BE ATTACHED TO THIS QUESTIONNAIRE

 Procédure(s) politique(s) sécurité / sûreté du sous-traitant

 The "Supplier and Subcontractor Charter" of the SPIE Group returned initialed on all pages, dated and signed
 Bank details (official document from the bank)
 A KBIS extract dated less than 3 months (extract of registration in the register of companies)
 A valid civil liability certificate
 Any document attesting a certification (ISO, MASE, ATEX or other) with the expiration date clearly marked
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 Brochure presenting the activity
 CSR evaluation form with scoring grid (if applicable)
 Code of conduct (if applicable)
 Organisation chart

STATEMENT

I, the undersigned, accept the general purchasing conditions of SPIE Oil & Gas Services, a copy of which has been given to me. I certify
that the information contained in this form is accurate and I undertake to inform you of any changes as soon as possible.
Name :__Budianto______________________ Titre:____________________

Signature: ____________________ Date:_September 30, 2022___________________

RESULT OF THE EVALUATION - part reserved for SPIE OGS

Components of the evaluation Performed Date Signature

Evaluation by the Procurement By:
Manager (in France) or the
Managing Director (in
affiliate/branch)
Evaluation by the Compliant Officer By:
(Classical DD or probity survey)

Conclusion Comments
☐ Satisfactory assessment
☐ Satisfactory evaluation subject to corrective actions Corrective actions to be taken:
Requested on :
Verification of the implementation of corrective actions:

☐ Unsatisfactory evaluation

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TYPOLOGY
Please select your activity(ies) from the following list:
CODE SUPPLIER TYPOLOGY (ENG) TYPOLOGIE FOURNISSEUR (FRA)
01 AIR TREATMENT UNITS & FILTRATION FILTRATION & UNITES DE TRAITEMENT DE L'AIR
02 AUTOMATION EQUIPMENT AUTOMATION - AUTOMATES PROGRAMMABLES
03 BROADCASTING BROADCASTING - TELEDIFFUSION - RADIODIFFUSION
04 BUILDING EQUIPMENT EQUIPEMENTS DE CHANTIER
05 CONSTRUCTION PRODUCTS MATERIAUX DE CONSTRUCTION
CONSOMMABLES DE CHANTIERS HORS ELECTRICITE (VIS,
06 PRODUCTION CONSUMABLES DISQUES, SILICON…)
07 EQUIPMENT RENTAL FOR SITES LOCATIONS DE MATERIEL POUR CHANTIER
08 RAW MATERIALS FOR PRODUCTION MATIERES PREMIERES POUR PRODUCTION
09 CABLES CABLES
10 SUPPORTS CABLES TRAYS SUPPORTAGES ET CHEMINEMENTS DE CABLES
11 SERVICES - IT SERVICES INFORMATIQUES
12 MATERIALS - IT EQUIPEMENTS INFORMATIQUES
13 INTERNET CONNECTION SERVICES INTERNET
14 INTERNET CONNECTIVITY EQUIPEMENTS DE CONNEXION AU RESEAU / INTERNET
15 DATA CENTER EQUIMENTS EQUIPEMENTS DATA CENTERS
16 DATA CENTER HOSTING HEBERGEURS DATA CENTER
17 DATA SECURITY SECURITE DES DONNEES
MATERIEL VDI, VIDEOSURVEILLANCE ET DE CONTRÔLES D'
18 VDI EQUIPMENT, VIDEO SURVEILLANCE AND ACCESS CONTROL ACCES
19 TELECOM OPERATORS OPERATEURS TELECOM
20 MOBILE TELECOM TELEPHONIE MOBILE
21 OPERATING SYSTEM - SOFTWARE SYSTÈME D'EXPLOITATION - LOGICIEL
22 FIRE & SAFETY EQUIPMENT MATERIEL SECURITE INCENDIE
23 INSTRUMENTATION & MEASURE MATERIEL DE MESURE & INSTRUMENTATION
24 ELECTRICAL CONSUMABLES CONSOMMABLES ELECTRIQUES
25 EQUIPPED ELECTRIC PANELS TABLEAUX ELECTRIQUES EQUIPES
26 ELECTRONIC COMPONENTS COMPOSANTS ELECTRONIQUES
27 HIGH AND MID VOLTAGE EQUIPMENT EQUIPEMENTS ELECTRIQUES HAUTES ET MOYENNES TENSIONS
28 LOW VOLTAGE EQUIPMENT APPAREILLAGE BASSE TENSION
29 GROUNDING MATERIAL MATERIELS DE MISE A LA TERRE
30 LIGHTING MATERIEL D' ECLAIRAGES
31 POWER CONVERTERS & GENERATORS CONVERTISSEURS & GENERATEURS D'ENERGIE
32 ELEVATOR EQUIPMENT MATERIEL POUR ASCENSEURS OU ELEVATEURS
33 HVAC DISTRIBUTION & PRODUCTION DISTRIBUTION & PRODUCTION HVAC
34 HYDRAULIC PIPE AND SUPPORT MATERIEL HYDRAULIQUE ( CONDUITS ET SUPPORTS)
35 ROTATING MACHINES MACHINES TOURNANTES
36 MECHANICAL COMPONENTS AND EQUIPMENT COMPOSANTS ET EQUIPEMENTS MECANIQUES
37 INDIVIDUAL AND POWER TOOLS OUTILLAGES INDIVIDUELS & ELECTRO PORTATIF
38 HEALTH AND SAFETY PRODUITS HYGIENES ET SECURITES
39 NUCLEAR EQUIPMENT MATERIEL POUR APPLICATIONS NUCLEAIRES
40 OIL & GAS MARKET EQUIPEMENTS SPECIFIQUES POUR APPLICATIONS OIL & GAZ
41 PHOTOVOLTAIC EQUIPMENT MATERIEL PHOTOVOLTAIQUE
42 REGULATING EQUIPMENT EQUIPEMENT dE REGULATION
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43 TRACTION EQUIPMENT MATERIEL DE TRACTION
44 ROAD INSTALLATION EQUIPEMENTS ROUTIERS
45 ENERGY (WATER, ELECTRICITY, GAS) & WASTE MANAGEMENT ENERGIE (EAU, ELECTRICITE, GAZ) ET GESTION DES DECHETS
46 ENVIRONMENTAL PROTECTION DEPARTMENT PROTECTION DE L'ENVIRONNEMENT
47 MATERIALS - GENERAL SUPPLIES AND FURNITURE CONSOMMABLES BUREAUTIQUES ET MOBILIERS DE BUREAUX
48 MEDICAL EQUIPMENT MATERIEL MEDICAL
49 MEDICAL PROFESSIONS AND ANALYSIS LABORATORIES PROFESSIONS MEDICALES ET LABORATOIRES D'ANALYSE
50 PERSONAL SAFETY SERVICES DE SECURITE
51 MATERIALS - REAL ESTATE MATERIELS POUR MAINTENANCE PARC IMMOBILIER
52 SERVICES - REAL ESTATE SERVICES - IMMOBILIER
PRESTATIONS DE SERVICES DIVERSES (JARDINNAGE,
53 VARIOUS SERVICES (GARDENING, CATERING...) RESTAURATION D'ENTREPRISE…)
54 SUBCONTRACTING-ENGINEERING SOUS TRAITANCES/ PRESTATIONS - ETUDES TECHNIQUES
55 SUBCONTRACTING-INSTALLATION SOUS-TRAITANCES - TRAVAUX ET INSTALLATIONS
SOUS TRAITANCES/ PRESTATIONS - MAINTENANCES
56 SUBCONTRACTING-MAINTENANCE MULTITECHNIQUES
57 SUBCONTRACTING-SOFT SERVICES SOUS TRAITANCES/ PRESTATIONS - GESTION DES LOCAUX
58 TEMPORARY WORK TRAVAIL TEMPORAIRE / INTERIM
HUMAN RESOURCES (RECRUITMENT AGENCY, CONSULTING, RESSOURCES HUMAINES (ORGANISME DE RECRUTEMENT, DE
59 TRAINING CENTER...) CONSEILS, CENTRES DE FORMATION…)
SUPPORT PROFESSIONAL SERVICES (ENGINEERING AND DESIGN SERVICES DE SUPPORT PROFESSIONNEL (BUREAU D'ETUDES,
60 OFFICE,CONSULTING…) CABINET CONSEIL...)
61 CHAMBERS OF COMMERCE, UNIONS,..... CHAMBRES DE COMMERCES, SYNDICALES,.....
COMMUNICATION MARKETING & SALES (PRINTING / COMMUNICATION (VENTES / MARKETING) (IMPRIMERIE /
SUBSCRIPTION / PRESS / GOODIES / ADVERTISING AGENCY / ABONNEMENT / PRESSE / GOODIES / AGENCE DE PUB /
62 EXHIBITIONS / FAIRS......) SALONS / FOIRES…)
63 FINANCIAL SERVICES SERVICES ET PRESTATIONS FINANCIERES
64 GIFTS, ALCOHOL, FLORISTS CADEAUX,ALCOOLS,FLEURISTES
65 INSURANCE ASSURANCES
66 LEGAL PRESTATIONS JURIDIQUES
LOGISTICS & TRANSPORTATION (FORWARDER / CARRIER / LOGISTIQUE ET TRANSPORTS (TRANSITAIRE / TRANSPORTEUR /
67 STORAGE / PACKER…) STOCKAGE / EMBALLEUR….)
ORGANISMES DE CONTROLE, DE CERTIFICATION, DE
68 CONTROL, CERTIFICATION AND QUALIFICATION BODIES QUALIFICATION
69 TRAVEL AGENCIES, TICKETING AGENCES DE VOYAGES,BILLETERIE
70 HOTELS,RESTAURANTS HOTELS,RESTAURANTS
71 CATERERS TRAITEURS
72 TAXI, PUBLIC TRANSPORT TAXIS,TRANSPORTS EN COMMUN
73 COURIERS, EXPRESS TRANSPORT, MESSENGERS MESSAGERIES,TRANSPORTS EXPRESS,COURSIER
74 SHORT TERM RENTALS VEHICLES LOCATIONS COURTES DUREES DE VEHICULES LEGERS
75 CAR FLEET PURCHASES & LONG TERM RENTALS ACHAT ET LOCATION LONGUE DUREE DE VEHICULES
76 MATERIALS - CAR FLEET PURCHASES & LONG TERM RENTALS EQUIPEMENTS POUR LA FLOTTE DE VEHICULES ACHATS & LLD
77 GARAGES, MAINTENANCE OR REPAIR OF VEHICLES GARAGES,ENTRETIENS OU REPARATIONS DE VEHICULES
78 VARIOUS SHELTERED WORKSHOPS ATELIERS PROTEGES DIVERS

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