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FORM PERSETUJUAN PELANGGAN

CLIENT APPROVAL FORM

Uji Lab / Lab Testing Uji Banding / Proficiency

I. INFORMASI UMUM PERUSAHAAN

COMPANY GENERAL INFORMATION

Nama Perusahaan
Company Name
Jenis Produk Makanan & Minuman Produk K3L
Types of products Food & Beverage K3L Product
Kecantikan & Perawatan Diri ALKES & PKRT
Beauty & Personal Care Medicial Device & Hygine Product
Farmasi Pakan, Pestisida & PSAT
Pharmaceutical Feed, Pesticides, & PSAT
Obat Tradisional & Suplemen Balai / Kedinasan
Traditional Medicine & Suplement Government Sales Operation
Penelitian / Kebutuhan Akademis
Research / Academic Purposes
Alamat
Address

Negara Asal Kode Pos

Origin Postal Code
Telephone Fax
Mobile No.
Nomor Registrasi Usaha VAT/NPWP No.
Company Registration No.
II. PERSONEL PENGHUBUNG
CONTACT PERSON

Nama Personel Keuangan

Name Finance Contact
Jabatan Jabatan
Designation Designation
Telephone Telephone
Ext. Ext.
Fax Fax
Mobile No. Mobile No.
Email Email
III. INFORMASI PENAGIHAN
INVOICE TO INFORMATION

Perusahaan Tertagih
Invoice to Company
Personel Penghubung
Main Contact
Alamat
Address
Telephone Fax
Mobile No.
Email
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IV. DESKRIPSI SAMPEL

SAMPLE DESCRIPTION

Nama Sampel Kode Permintaan Uji Metode/Regulasi*

No. Name of Sample Code Analysis Request Methode/Regulation*

*Jika Ada / If Any

Permintaan Reguler Urgent* Very Urgent*

layanan
Service Requested :
*Syarat dan ketentuan berlaku / Term and condition applied
*Status uji regular, urgent, dan very urgent memiliki harga yang bereda / All services may vary in price

Dengan ini saya mengonfirmasi bahwa informasi di atas ialah benar

I hereby confirm that the information above is true

Tanda tangan / Nama / Tanggal Supplier / Cap Basah

Signature / Name / Date Supplier/ Company Stamp

Harap lampirkan photocopy NPWP / KTP

Please attach photocopy of valid NPWP/ ID (KTP)

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