KYC REQUIREMENT FORM

1 Date of Data Entry/Update : 15-Apr-21

2 Name of Party : PT NAUTICA SURVEI INDONESIA
3 Address : Gd. Rumiza 2nd Floor, Jalan Guntur No. 22, Setiabudi, Jakarta Selatan, 12980
4 Place of Incorporation : Gd. Rumiza 2nd Floor, Jalan Guntur No. 22, Setiabudi, Jakarta Selatan, 12980
5 Date of Incoporation : 25-May-12
6 Line of Business : Marine, Offshore & Cargo Surveyor and Consultant, Technical Inspection and Specialized Services

7 Latest Capital Structure : Rp. 2.800.000.000

8 Shareholders: :

Name % Ownership
Dr. Indaryati Swarna Dewi Motik 66%
Ir. M Bascharul Asana 6%
Mohammad Tarmizi Onies Ismail 25%
Yovie Yovanka CH 3%

9 Business Group: -
10 Directors: Copy of Identity Card
Term of Office (date) (Tick if Available)
Ir Daud Yogasara 15 Oktober 2019 P

11 Commissioners (if Applicable): Copy of Identity Card

Term of Office (date) (Tick if Available)
Dr. Indaryati Swarna Dewi Motik 15 Oktober 2019 P
Ir. M Bascharul Asana 15 Oktober 2019 P

12 Material License/Permit: (please attach copy)

Expiry Dates (Tick if Available)
Surat Izin Usaha Jasa Survey 23-Nov-21 P
Surat Izin Usaha Perdagangan 1-Nov-21 P
Perusahaan Jasa Keselamatan dan Kesehatan Kerja 21-Sep-21 P

13 Relationship with Adaro Group (State Adaro Group Company): -

14 Nature of Relationship: -
Year

15 Applicant :
Name : Ivan Saprial Dina
Position : Account Executive

Department : Marketing