NDTINSPECTIONSOLUTIONS

MetaphasePhasedArrayAutomatedUltrasonicsUTScan
StandardNDTAdvancedNDTPipelineConstruction
NewConstructionThirdPartyInspection/Auditing

Indonesia

FormNo.:
IssueDate.:
RevNo.:

SUPPLIER FORM
Date

:
(Request Date)

To

From

Purchasing
(Requester Name)

(Dept.)

I.

SUPPLIER DATA

1.1
1.2

Supplier Name
Supplier Address

1.3

Tel/Fax No./
Mobile (HP)
Contact Person &
Title

:
:

PT. Mac Marine Indonesia

Komp. Acellence Blok A No.11, Batam Centre

0778 7048789/ 0778 - 7048789

Mr. Nurul Qomar

(including Post Code)

1.4

/ Managing Director

(Contact Person)

1.5

E-Mail Address

info@mac-marine.com

:
:
:
:
:
:
:
:

Bank Mandiri
N/A
Batam
Indonesia
N/A
NURUL QOMAR
109-0006734123
N/A

(Title/Position)

BANK PAYMENT DETAIL

1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13

2.

Bank
Address
City
Country
Tel No
Beneficiarys Name
Account No
Swift Code
Supplier category :
Stockist

Service Provider

Mill

Manufacturer/Fabricator/Subcontractor

General Trade
One Time Supplier

Equipment

Logistis and shipping.(Pls specify)

3.

Supplier Quality Systems Status :

ISO
9001 : 2000
Exp : 26 September 2017
(Pls. Specifiy Type & Validity)

Other:
(Pls. Specify)

UTQI-FRM-112 rev1

Page1 of2
KOmpPalmSpringBlokD2No.8,SeiPanasBatam,Indonesia29436,Phone:(62778)466 915,Fax:(62778)464494,Web:www.utquality.com

NDTINSPECTIONSOLUTIONS
MetaphasePhasedArrayAutomatedUltrasonicsUTScan
StandardNDTAdvancedNDTPipelineConstruction
NewConstructionThirdPartyInspection/Auditing

Indonesia

4.

Products to be Approved :
No.

Syteline Item Master #

Description
4.1
4.2
4.3
4.4

5.

Logistics
Shipping

Availablility of Supported Documents required:

(Pls. Attached - All data must be valid for min. 3 months after the date of reques)

Local Supplier
Akte Pendirian
PKP
NPWP
SIUPAL
Company Profile

Overseas Supplier
Company Profile
Experience List
Quality Certificates or other Quality Documents
Bank Reference Information

6.

Akte Pendirian*
6.1 Date :
6.2 No :
6.3 Notaries Name :

7.

SIUP ( Surat Ijin Usaha Perusahaan Angkutan Laut )*

7.1
7.2
7.3
7.4

Date :
No :
Expired date :
Line Business :

16 MAY 2014
AHU-08920.40.10.2014
Yulianti, SH.,M.KN
TBA
TBA
TBA
Shipping and Logistics

8.

NPWP / Tax Registration Number*

No :
70.422.585.3-215.000
Register Date : 16-06-2014

9.

Additional Information (for Syteline purpose only):

12.1
Currency
:
IDR/ SGD/ USD
12.2
Shipping Method
:
Air Freight/ Sea Freight/ Handcarry
12.3
Payment Term
:
30 Days

10. Does the price included PPN * ( Value Added Tax ) or GST ?

Yes

No

11. Does the transaction should be paid PPH ( Income Tax )* ?

Yes
No
If yes, What Type of PPH and How Many the Charges
Type :.. Charges %.................

12. Does the price included PPH * ?

Yes
No
* For Supplier from Indonesia Only

UTQI-FRM-112 rev1

Page2 of2
KOmpPalmSpringBlokD2No.8,SeiPanasBatam,Indonesia29436,Phone:(62778)466 915,Fax:(62778)464494,Web:www.utquality.com