Pls select one from drop-down list.

1. Corporate payment: our company directly

Date to fill in this application
pays to supplier.
form please use your name in your
2. Trip reimbursement: trip reimbursement
please follow the date format employment contract.
should pre-apply before trip.
of example below
3. Daily reimbursement: reimbursement
other than trip reimbursement.

流程分类 申请日期 申请人

Type of application process Application date Applicant

Corporate Payment 1/12/2023 HR

 Pls select one from drop-down
pls fill in one row for one voucher/invoice Please use number format
list.

事由 申请金额 币种
Reason for application Applied amount Currency

TIS - Medical Insurance Payment (Jan 2023) 2,769,500.00 IDR

 If a reimbursement,please fill If a reimbursement,please fill
If a reimbursement,please fill in name of
in bank of individual in bank account of individual
individual applicant.
applicant. applicant.
If a corporate payment,please fill in supplier's
If a corporate payment,please If a corporate payment,please
name.
fill in supplier's bank. fill in supplier's bank account.

对方银行 对方账户
对方名称
Supplier/individual Supplier/individual
Supplier/individual name
bank name bank account

8988890080063745 BPJS Kesehatan Mandiri

 Pls select one from drop-down list.
Select the company you belong to
ie. Which company you sign an employment contract with.

付款公司主体
Payment Company

Teknologi Indonesia Sentosa