PT.

SEMEN JAWA
Supplier/Contractor Registration Form PROCUREMENT DEPT.

Name of Supplier / Vendor : PT SEMEN JAWA Tax ID : 01.606.198.8-415.000

Address : JL. XXXX

Name of Bank : 1) Bank Central Asia ( VA XXXXXXXXX / XXX QQ PT SEMEN JAWA) 2)

Name of authorized person Possition Signature

1) ARIF RAMADHANI FINANCE DEPT HEAD

2)

3)

No. Materials / Services Manufacturer Agent

(Brand & Producing Country) / Provider

01. Waste Cello Manufacturer

1) if space is not enough, please continue to fill up back side Signature Suppliers

2) Please see the terms on the back. ( )

3) Please seal the logo of company here ==============> Date

Below space for company officer

Addition data : Reviewer Proposer Approval

The result Register Not Register Date : Date : Date :

FM-PC-001