Synnex Metrodata Indonesia Credit Application

Page 1

Email to : Collection_SMI@metrodata.co.id Please include current and previous year financial statements

Date : ____________

Total Asset : IDR _________________ Total Current Asset : IDR _______________________

Total Liabilities IDR

Type of Account:

Others __________________________
Distributor Reseller Strategic Accounts

COMPANY INFORMATION

SELECT ONE: Corporation Partnership Sole Proprietorship

PUBLIC OR PRIVATE COMPANY: Public Private
BUSINESS NAME: PT.BERKAT SUBUR LESTARI

ADDRESS: KOMPLEK PERGUDANGAN BUMI MASPION ROMOKALISARI IX.C NO.15

COUNTRY: IND Telp : +62 822-3111-5005 FAX : ______________________

DELIVERY ADDRESS (IF DEFFERENT) : __________________________________________________________________________________

WEBSITE:

DATE COMPANY ESTABLISHED: ______________________________

ANNUAL SALES (IDR) : NO. OF EMPLOYEES: __5____________________

NAME OF HOLDING COMPANY (IF ANY) : _______________________________________________________________________________

NAMES OF OFFICERS (Required for non-public companies)

PRESIDENT/CEO/OWNER: RONNY SINNATA

Direct Phone Line: +62 822-3111-5005 E-mail: ___________________________

CFO/COO/CONTROLLER:

Direct Phone Line: E-mail: ___________________________

ACCOUNTING CONTACT (Required)

ACCOUNTS PAYABLE CONTACT: _________________

Direct Fax Line:+62 822-3111-5005 E-mail: ___________________________

REQUEST LIMIT& TOP (Required)

LIMIT : ______________________

TERM OF PAYMENT : _______CASH________________

757930101.xls Review Form

 Synnex Metrodata Indonesia Credit Application
Page 2

TRADE REFERENCES (Required)

COMPANY NAME:

CONTACT: E-MAIL :
FAX:
PHONE:
CURRENT LINE OF CREDIT: _____________________
PAYMENT TERMS:

COMPANY NAME:

CONTACT: E-MAIL :
FAX:
PHONE:
CURRENT LINE OF CREDIT: _____________________
PAYMENT TERMS:

BANK REFERENCE (Required)

BANK NAME :

CHECKING ACCOUNT #:

SAVINGS ACCOUNT #:

CONTACT:

PHONE :

FAX :

CURRENT LINE OF CREDIT:

GENERAL AGREEMENT
As an inducement to grant credit, the applicant warrants that the information submitted is true and correct. Metrodata is authorized to
investigate the trade and bank references listed above. The Applicant further releases all banks, businesses, and persons identified
on this application to furnish any and all information requested by Metrodata or it’s representatives, by telephone or written
correspondence whichever Metrodata requests.

___________________ ____________ ______________

Name Signature Title Date

Document must be submitted Check list Check list

1 Akta Perusahaan* 8 Bank Referensi – Asli

2 KTP penanggung jawab/Direksi (* / **) 9 Rekening Koran – last three months
3 NPWP Perusahaan* 10 Laporan Keuangan – last three years (audited)
4 Surat Pengukuhan PKP* 11 Bilyet Giro - Jaminan
5 Tanda Daftar Perusahaan* 12 Foto lokasi kantor/toko (tampak luar)**
6 Surat Izin Usaha Perdagangan* 13 Foto lokasi kantor/toko (tampak dalam)**
7 Surat Izin Tempat Usaha
Note : * Mandatory for PKP
** Mandatory for Non PKP

757930101.xls Review Form