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  • SIG - Form Client Approval

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    AriAkbar
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    This two-page document is a client approval form containing information about a company requesting laboratory testing of food samples. On page one, it provides the company's general information including name, address, contact person, and invoice details. Page two describes the sample being submitted, requesting microbiological testing of dates for mold, E. coli, and ALT. The client confirms the accuracy of the information and approval is indicated with a signature and date along with supplier stamp.

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    Original Title

    01. SIG - Form Client Approval (1)

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    This two-page document is a client approval form containing information about a company requesting laboratory testing of food samples. On page one, it provides the company's general information including name, address, contact person, and invoice details. Page two describes the sample being submitted, requesting microbiological testing of dates for mold, E. coli, and ALT. The client confirms the accuracy of the information and approval is indicated with a signature and date along with supplier stamp.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    77 views2 pages

    SIG - Form Client Approval

    Uploaded by

    AriAkbar
    This two-page document is a client approval form containing information about a company requesting laboratory testing of food samples. On page one, it provides the company's general information including name, address, contact person, and invoice details. Page two describes the sample being submitted, requesting microbiological testing of dates for mold, E. coli, and ALT. The client confirms the accuracy of the information and approval is indicated with a signature and date along with supplier stamp.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    Page 1 of 2

    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 product 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 Graha Mozaik, Jl. Otista Raya No. 40, Bidara Cina, Jatinegara
    Address Jakarta Timur 13330

    Negara Asal Indonesia Kode Pos 13330


    Origin Postal Code
    Telephone Fax
    Mobile No. 081293987215
    Nomor Registrasi Usaha VAT/NPWP No. 95.495.743.7-002.000
    Company Registration No.
    II. PERSONEL PENGHUBUNG
    CONTACT PERSON

    Nama Ari Akbar Personel Keuangan


    Name Finance Contact
    Jabatan Karyawan Jabatan
    Designation Designation
    Telephone - Telephone
    Ext. - Ext.
    Fax - Fax
    Mobile No. 081293987215 Mobile No.
    Email ariakbar8@gmail.com Email
    III. INFORMASI PENAGIHAN
    INVOICE TO INFORMATION

    Perusahaan Tertagih PT. Anugrah Mozaik Indojaya


    Invoice to Company
    Personel Penghubung Ari Akbar
    Main Contact
    Alamat Graha Mozaik, Jl. Otista Raya No. 40, Bidara Cina, Jatinegara
    Address Jakarta Timur 13330
    Telephone Fax -
    Mobile No. 081293987215
    Email ariakbar8@gmail.com
    Page 2 of 2

    IV. DESKRIPSI SAMPEL


    SAMPLE DESCRIPTION

    Nama Sampel Kode Permintaan Uji Metode/Regulasi*


    No. Name of Sample Code Analysis Request Methode/Regulation*
    1 Kurma / Dates Mikrobiologi :
    1. Kapang
    2. E. Coli
    3. ALT

    *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)

    Halaman ini dapat diperbanyak


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