QR-GS-PUR-006 Rev 00 Supplier Assessment & Qual. CNTRL

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SUPPLIER ASSESSMENT & QUALITY CONTROL

SUPPLIER SURVEY FORM - Page 1

Please fill & return this form to

A. Business Name & Address of Supplier


Company Name : PT. Mandala Hibar Buana
Office Address : Komplek Bekasi Town Square Blok G-7

Stoking Locations : Komplek Bekasi Town Square Blok G-6

Telp No/Fax : 021 - 888397563


Person to Contact / Position : Jessica Rohma / Marketing
B. Registration, Incorporation & Financial Standing

Type of Registration : NIB PT. Mandala Hibar Buana


Registration No : 8120117201821
Date Registered / Incorporated : 12 December 2018
Place Registrated / Incorporated : Jakarta

Type of Business : ( ) Sole Proprietor


( ) Partnership
( ) Corporation

Nature Business ( ) Manufacture


( ) Distributor
( ) Contractor
( ) Manufacturer Representative
( ) Others, please specify

Name Major Banker with full Address :

Prepared By Check By Approved By

QR-GS-PUR-006 Rev00

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