PT.

SURYA RENGO CONTAINERS

CUSTOMER APPLICATION FORM

(Lembar Aplikasi Pelanggan)

Please fill in capital letter (semua tulisan menggunakan huruf capital)

COMPANY PROFILE ( DATA PERUSAHAAN )

New Customer (customer baru) Change (perubahan data)

I. GENERAL INFORMATION (INFORMASI UMUM ) :

TITLE *) PT X CV PD / UD Representative Office ( Perwakilan )

( Badan Usaha ) Koperasi Yayasan Personal ( Perorangan ) Others

COMPANY STATUS *) PMA X PMDN Joint Venture Perusahaan Negara

( Status Badan Usaha )

COMPANY NAME *)
C V . N I F A N D A T A M A W I J A Y A A R TA
( Nama Perusahaan)

PARENT / GROUP COMPANY

( Nama Perusahaan Induk / Group) -

BUSSINESS LINE *) Industry / Manufacture Trading / General Trading Offsett Printing

( Jenis Usaha ) Sole Agent / Sole Distributor Transporter X Service / Jasa Others

PRODUCT ITEM ( Jenis Produk ) BRAND ( Merek )

SALES /YEAR *) 1 8 0 0 0 0 ton / kgs / pcs /others

Rp.
(Penjualan /tahun) 1 , 8 0 0 , 0 0 0 , 0 0 0

EMPLOYEE NUMBER Fixed Outsource

9
(Junlah Pegawai) (Tetap ) (Tidak Tetap )

DEED NUMBER & DATE Tanggal

(No & Tgl. Akte Pendirian Perusahaan) 1 0 2 2 3 5 1 0 1 9 6 9 (date) 1 9 0 2 2 2

NOTARY
( Notaris ) M A M A N S U M A N T R I S H

SIUP *) Tanggal
( Trade Business Licence) 0 0 4 4 10 23 2 0 1 5 (date) 2 3 1 2 1 9

NPWP *) Tanggal
0 2 , 5 5 3 , 1 6 1 , 7 4 2 6 , 0 0 0
( Tax ID Number ) (date) 2 2 0 5 0 6

OWNERSHIP STRUCTURE *) ( THE LATEST ) ( Struktur Kepemilikan terakhir )

Name Position Share (%) Phone No.

I W A N , B D I R U T 3 2 1 6 6 8

KEY MANAGEMENT/OFFICERS*) ( Susunan Penanggung Jawab Perusahaan )

Position Position Phone No. / Ext No. Email address

Direktur Utama I W A N , B 0 8 1 2 2 2 1 7 0 6 8

Direktur Operasional

Direktur Keuangan W A T I

General Manager H E R U , S 0 8 5 7 9 7 4 7 8 2 7 8

Note : *) wajib diisi/dilengkapi (mandatory) Page : 1 / 7

Note : *) wajib diisi/dilengkapi (mandatory) Page : 2 / 7
 D S , K A L I W A D A S B L O K B A N T E N A N
BUSINESS ADDRESS*) Street / Jalan

RT , 0 5 RW , 0 1 S U M B E R C I R E B O N
( Alamat kantor Pusat )
C I R E B O N Province / Propinsi J A B A R
City / Kota
Owned Lease Postal Code / Kode Pos

BUSINESS PHONE*) 0 2 3 1 3 2 1 6 6 8 Fax 0 2 3 1 3 2 1 6 6 8

( No. Telp. ) ( No. Fax )

HOMEPAGE
( Alamat e-mail & website ) N I F A N D A 8 0 0@ Y A H O O , C O M

PLANT ADDRESS (1)*) Street / Jalan D S , K A L I W A D A S B L O K B A N T E N A N

( Alamat ) RT , 0 5 RW , 0 1 S U M B E R C I R E B O N

City / Kota C I R E B O N Province / Propinsi J A B A R

Owned Lease X Delivery address Postal Code / Kode Pos

Please thick the box if delivery address is same, if different please fill as below.
(Diberi tanda bila alamat kirim sama, bila berbeda mohon diketik dibawah ini)

PLANT ADDRESS (2)*) Street / Jalan -

( Alamat ) -

City / Kota - Province / Propinsi

Owned Lease Delivery address Postal Code / Kode Pos

Please thick the box if delivery address is same, if different please fill as below.
(Diberi tanda bila alamat kirim sama, bila berbeda mohon diketik dibawah ini)

DELIVERY ADDRESS*) Street / Jalan -

( Alamat Pengiriman) -

City / Kota - Province / Propinsi

Owned Lease Bonded Area (EPTE) Postal Code / Kode Pos

CONTACT PERSON*)
FACTORY MANAGER PHONE
H E R U . S HP NO. 0 8 5 7 9 7 4 7 8 2 7 8

WAREHOUSE DEPARTMENT*) 1. H E R U . S HP NO. 1. 0 8 5 7 9 7 4 7 8 2 7 8

2. 2.

3. 3.

MAJOR CUSTOMERS*) ( Pelanggan Utama)

Name Product Sold Ave. Monthly Sales Terms Contact Person Phone No.

II. PURCHASING INFORMATION (INFORMASI PEMBELIAN) :

CONTACT PERSON*) 1. I W A N , B A G U S , H POSITION*) 1. D I R U T

(Penanggung jawab) 2. ( Jabatan ) 2.

PHONE*) ( No. Telp. ) 1. 0 8 1 2 2 2 1 7 0 6 8 Fax 1. 0 2 3 1 3 2 1 6 6 8

MOBILE PHONE 2. ( No. Fax ) 2.

MAJOR SUPPLIERS ( Pemasok Utama)

Name Material Purchased Ave. Monthly Purchased Terms Contact Person Phone No.

Note : *) wajib diisi/dilengkapi (mandatory) Page : 3 / 7

Note : *) wajib diisi/dilengkapi (mandatory) Page : 4 / 7
 EXISTING SUPPLIER FOR CARTON BOX PACKAGING ( Pemasok Karton saat ini)
Name Starting suppy Ave. Monthly Purchased Terms Contact Person Phone No.

III. FINANCE INFORMATION (INFORMASI KEUANGAN) :

CONTACT PERSON*) 1. I W A N , B A G U S POSITION 1. D I R U T

(Penanggung jawab) 2. ( Jabatan ) 2.

3. 3.

4. 4.

Email address*) ( alamat email ) 1. N I F A N D A 8 0 0 @ HP NO. 0 8 1 2 2 2 1 7 0 6 8

2. Y A H O O , C O M (nomor handphone)

3.

4.

BILLING ADDRESS*) Street / Jalan D S , K A L I W A D A S B L O K B A N T E N A N

( Alamat Penagihan) RT , 0 5 RW , 0 1 S U M B E R C I R E B O N

City / Kota C I R E B O N Province / Propinsi J A B A R

Owned Lease Postal Code / Kode Pos

PHONE*) 0 2 3 1 3 2 1 6 6 8 Fax 0 2 3 1 3 2 1 6 6 8

( No. Telp. ) ( No. Fax )

BILLING DAY*) J U M A T Time 1 3, 0 0 S D 1 5 0 0

( Hari Penagihan) ( Jam )

VAT*) Tax Invoice Bonded Area (EPTE)

( PPN ) ( Faktur Pajak ) ( Kawasan Berikat )

Bank Information Accounts ( Informasi rekening Bank)

Type of
Bank Name Account No. Account Name Swift Code Account

Bank Name

B N I 0 1 7 7 4 1 8 9 7 9 I W A N , B A G U S H E R M A W A N

Bank Credit Facilities ( Fasilitas Kredit yang dimiliki )

Bank / Branch Type of Account Amount Kind of Loan Secured/Unsecured

PAYMENT METHODS*) CBD (cash before delivery) Cash Credit Contract

( Metode Pembayaran ) ( Pembayaran dimuka ) (Tunai) (Kredit) (Sesuai kontrak)

PAYMENT TYPE*) CHEQUE/BILYET GIRO Transfer to Bank

( Jenis Pembayaran ) ( Cek / BG ) X ( transfer melalui Bank )

TERM OF PAYMENT*) Days after goods received

( Jangka Waktu Pembayaran ) ( Hari setelah barang diterima )

Note : *) wajib diisi/dilengkapi (mandatory) Page : 5 / 7

Note : *) wajib diisi/dilengkapi (mandatory) Page : 6 / 7
 IV. CUSTOMERS STATEMENT :

We hereby confirm that the above-mentioned data is truthful and correct in accordance with the conditions at the time this statement was made,
and in case a change occurs, we will be notified in advance. ( Dengan ini kami menyatakan bahwa informasi dan data yang kami berikan
adalah benar dan sesuai dengan kondisi pada saat pernyataan ini dibuat dan bila ada perubahan kami akan memberitahukan segera).

CUSTOMER STAMP : SIGNATURE :

Name :
Position : Date :

CUSTOMER REFERENCE DATA ( DATA REFERENSI PELANGGAN ) :

COMPANY ( Perusahaan ) PERSONAL ( Perorangan / Individu )

X Company Profile / Data Perusahaan Copy KTP / KIMS / Pasport / SIM *)
X Copy Deed of establishment / Akte Pendirian Perusahaan Surat Pernyataan Customer*)
X Copy SIUP*) Copy SIUP*)
X Copy NPWP*) Copy NPWP*)
Copy PKP*) Copy PKP
X Copy TDP*) Copy TDP*)
X Copy Domisili Perusahaan Copy Domisili Perusahaan
X Surat Perjanjian Jual Beli*) Surat Perjanjian Jual Beli*)
Customer visit sheet Customer visit sheet
Plant / Factory / Office Foto*) Plant / Factory / Office Foto*)

PT. SURYA RENGO CONTAINERS APPROVAL :

CUSTOMER CODE

Rp.
CREDIT LIMIT

Entried by : Checked by : Approved by : Final Approved by :

Sales Ex. / Int. Sales Finance & Accounting Mgr Sales Manager /Factory Manager Board of Director
Date : Date : Date : Date :

Note : *) wajib diisi/dilengkapi (mandatory) Page : 7 / 7