Form MI-QSP-03-01-F06

Revision 03

NEW CUSTOMER DATA

GENERAL INFORMATION
A

1 Date :

2 Company/Customer Name :
Master Customer Name (fill with same name of
3 customer if New Master) :

4 Agent :

5 Area/Province :

6 Contact Person :

Owner (President Director or Director) Name :

Email :

Phone Number :

Mobile Phone Number :

R&D Name :

Email :

Phone Number :

Mobile Phone Number :

7 Address :

Corporate :

City :

Phone Number :

R&D Centre :

City :

Phone Number :
 Form MI-QSP-03-01-F06
Revision 03

COMMERCIAL PURPOSE
B
Purchasing Contact Person
1 :

2 Job Title :

3 Email Contact Person :

4 Phone Number :

5 Fax Number :

6 Mobile Phone Number :

DELIVERY PURPOSE
C

1 Delivery Address (1) :

2 Contact Person :

3 Email Contact Person :

4 Phone No :

5 Delivery Address (2) :

6 Contact Person :

7 Email Contact Person :

8 Phone No :

9 Delivery Address (3)

10 Contact Person :

11 Email Contact Person :

12 Phone No :
 Form MI-QSP-03-01-F06
Revision 03

DISTRIBUTION INVOICE & FAKTUR (TUKAR FAKTUR)

D

1 Contact Person :

2 Job Title :

3 Email Contact Person :

4 Phone Number :

5 Fax Number :

6 Mobile Phone Number :

7 Faktur/Invoice Delivery Address :

8 Preffered Day :

9 Preffered Date :

10 Operational Time :

PAYMENT PURPOSE
E

1 Contact Person :

2 Job Title :

3 Email Contact Person :

4 Phone Number :

5 Fax Number :

6 Mobile Phone Number :

TAX PURPOSE
F

1 Name of PKP :

2 NPWP :

3 Address of PKP :

4 Contact Person :

5 Job Title :
 Form MI-QSP-03-01-F06
Revision 03

6 Email Contact Person :

7 Phone Number :

8 Mobile Phone Number :

9 Tax Faktur Delivery Addres :

G Mandatory Documents Needed for Tax

Copy of SPPKP (Surat Pengukuhan Pengusaha Kena
1 Pajak)
2 Copy of NPWP (Nomor Pokok Wajib Pajak)
3 Copy of SKT (Surat Keterangan Terdaftar)
 Form MI-QSP-03-01-F06
Revision 03

NEW CUSTOMER DATA

21 November 2023

CV TEH BAHAN MENTAH

CV TEH BAHAN MENTAH

CENTRAL JAVA

6282136790811

BERNABAS ADITYA JUNIARSENA

cv.tehbahanmentah@gmail.com

6281271646854

Aan Gunawan

gunawan.aan006@gmail.com

6285649589740

Jalan Sam Ratulangi Gg. Kasuari I No. 2, Kerten, Laweyan, Kota

Surakarta, Jawa Tengah, 57143.

CV TEH BAHAN MENTAH

CENTRAL JAVA

6282136790811

Aan Gunawan

CENTRAL JAVA

6285649589740
 Form MI-QSP-03-01-F06
Revision 03

Yona Dwi Prasetyo

CEO

fstiky24@gmail.com

6282136790811

Jl. Ngemplak Cilik, RT. 01/ RW 03, Wirogunan, Kartosuro, Sukoharjo, Jawa
Tengah

Yona Dwi Prasetyo

cv.tehbahanmentah@gmail.com

6282136790811
 Form MI-QSP-03-01-F06
Revision 03

Tita Ria Adi

Tax Staff

cv.tehbahanmentah@gmail.com

6282136790811
Jalan Adi Sucipto No. 42, Desa/Kelurahan Blulukan, Kec. Colomadu, Kab.
Karanganyar, Provinsi Jawa Tengah Kode Pos: 57174

Senin-Sabtu 09.00-15.00

Yona Dwi Prasetyo :

CEO

cv.tehbahanmentah@gmail.com

6282136790811
 Form MI-QSP-03-01-F06
Revision 03

{ jika perorangan tidak perlu dilampirkan}

{ jika tidak mempunyai NPWP, harap dilampirkan Copy KTP}
{ jika perorangan tidak perlu dilampirkan}
 Form MI-QSP-03-01-F06
Revision 03

kan Copy KTP}