EMP EMP
Wisma Mulia 22nd Floor, Jl. Jend. Gatot Subroto Kav. 42, Jakarta 12710 Telephone: (62-21) 5290-6100; 5290-6200 Facsimile: (62-21) 5290-6300
VENDOR REGISTRATION FORM Formulir Pendaftaran Rekanan SUBJECT : FEED OF GAS SALES PLANT PROJECT Subjek BID NO. Nomor Tender
:
3257 / 203552 / SO / MS /OPS / OT / XI / 09
VENDOR NAME Nama Rekanan
:
PT. ERRAENERSI KONSTRUKSINDO
MAIN OFFICE ADDRESS Alamat Kantor Pusat
:
Graha Kanaan 6th fl. Jl. TB. Simatupang Kav.18 Cilandak Barat Jakarta 12430
TELEPHONE NUMBER Nomor Telepon
:
62-21 7591 7242
FACSIMILE NUMBER Nomor Faksimili
:
62-21 7590 5660
E-MAIL ADDRESS Alamat e-mail
:
[email protected]
I. GENERAL INFORMATION I. Informasi Umum
* ADDITIONAL INFORMATION (IF APPLICABLE) * Informasi Tambahan (Jika Ada) BRANCH OFFICE ADDRESS Alamat Kantor Cabang
:
TELEPHONE NUMBER Nomor Telepon
:
FACSIMILE NUMBER Nomor Faksimili
:
E-MAIL ADDRESS Alamat e-mail
:
PRINCIPAL NAME Nama Prinsipal
:
PRINCIPAL ADDRESS Alamat Prinsipal
:
CITY Kota
:
COUNTRY Negara
:
TELEPHONE NUMBER Nomor Telepon
:
FACSIMILE NUMBER Nomor Faksimili
:
N.A
Page 1 of 7
EMP EMP
Wisma Mulia 22nd Floor, Jl. Jend. Gatot Subroto Kav. 42, Jakarta 12710 Telephone: (62-21) 5290-6100; 5290-6200 Facsimile: (62-21) 5290-6300
E-MAIL ADDRESS Alamat e-mail
:
II. STATUS OF OWNERSHIP II. Status Kepemilikan SHAREHOLDERS Pemegang Saham
:
1. Sri Kayati Sugiyarto 2. Bambang Nugroho Gyat 3. Sugijarto Padmopandojo 4. Hasto Baskoro
BOARD OF COMMISSIONERS Dewan Komisaris
:
1. Sugijarto Padmopandojo 2. 3. 4.
BOARD OF DIRECTORS Dewan Direksi
:
SALESMAN FOR EMP Perwakilan untuk EMP
:
NAME
ID NO / KTP / KITAS
1. Bambang Nugroho Gyat
No. 09.5307.010164.0381
2. Hasto Baskoro
No. 09.5206.190462.0335
3.
No.
4.
No.
1. N.A 2. 3. 4.
STATUS OF OWNERSHIP Status Kepemilikan
:
DO YOU HAVE ANY AFFILIATED COMPANY IN EMP? Apakah Anda Memiliki Perusahaan Afiliasi di EMP?
N.A
: No
IF YES, LIST Jika Ya, Sebutkan NO. No.
COMPANY NAME Nama Perusahaan
VENDOR CODE Kode Rekanan
ADDRESS Alamat
FINANCIAL QUALIFICATION
1 2 3 4 5 Page 2 of 7
EMP EMP
Wisma Mulia 22nd Floor, Jl. Jend. Gatot Subroto Kav. 42, Jakarta 12710 Telephone: (62-21) 5290-6100; 5290-6200 Facsimile: (62-21) 5290-6300
6 7 8 9 10 IF YOU DO NOT ADVISE EMP OF YOUR AFFILIATED COMPANIES, AND EMP AT A SUBSEQUENT DATE BECOME AWARE OF SUCH AFFILIATIONS, EMP CONSIDER YOUR INTENTIONS TO BE UNETHICAL AND WE RESERVE THE RIGHT TO DISCONTINUE FURTHER REGISTRATION OR TRANSACTIONS WITH YOUR COMPANY. Bila Rekanan Tidak Mengaku Adanya Perusahaan Seafiliasi yang Terdaftar di EMP dan Suatu Saat EMP Menemukannya, Maka EMP Menganggap Rekanan Sebagai Tidak Etis dan EMP Berhak Membatalkan Pendaftaran atau Transaksi Lebih Lanjut dengan Rekanan Bersangkutan.
HOW MANY CUSTOMERS DO YOU HAVE CURRENTLY? Berapakah Jumlah Pelanggan yang Anda Miliki Saat ini?
:
Banyak. Sebagian seperti pada table dibawah.
SHOW LIST IF ANSWER IS NOT NONE. LIST YOUR TOP CUSTOMERS (MAX. 10) Apabila Jawaban Anda Ada, Sebutkan Pelanggan Anda (Maksimum 10) NO CUSTOMER’S NAME MAJOR PO/CONTRACT VALUE . Nama Pelanggan GOODS/SERVICES Nilai PO/Kontrak No. Barang/Jasa 1
PT. Perusahaan Gas Engineering & PMC Negara
2
PT. Pertamina Gas
FEED
3
ConocoPhilips Indonesia
Detail Engineering
4
Santos (Oyong), Ltd Design Engineering
5
Chevron Pacific Indonesia
EPC
6
Total EP Indonesie
Engineering Blanket
7
Ustrans Gas
Detail Design Engineering
8
KODECO Energy, Ltd
Technical Support Services
9
VICO Indonesia
Techincal Support Services
10
Amerada Hess (Jambi Merang)
Detail design Engineering
DO YOU HAVE ANY BUSINESS WITH OTHER OIL & GAS COMPANIES IN INDONESIA? Page 3 of 7
EMP EMP
Wisma Mulia 22nd Floor, Jl. Jend. Gatot Subroto Kav. 42, Jakarta 12710 Telephone: (62-21) 5290-6100; 5290-6200 Facsimile: (62-21) 5290-6300
Apakah Perusahaan Anda Berbisnis dengan Perusahaan Minyak & Gas Lainnya di Indonesia?
III. BUSINESS STATUS AND STRATEGY III. Status Bisnis dan Strategi NOTARY CERTIFICATE NUMBER : 2 Nomor Akte Notaris NOTARY CERTIFICATE ISSUED DATE Tanggal Dikeluarkan Akte Notaris
: 01 September 1995
SIUP NUMBER Nomor SIUP
: 06287 / 1.824.271
SIUP ISSUED DATE Tanggal Dikeluarkan SIUP
: 19 September 2008
SIUJK NUMBER Nomor SIUJK
: 3.601046.09.3171.3.00587 (Konstruksi)
TDP NUMBER Nomor TDP
: 09.03.1.74.26886
TDP ISSUED DATE Tanggal Dikeluarkan TDP
: 9-10- 2008
DOMICILE INFORMATION NUMBER Nomor Surat Keterangan Domisili
: 2545/1.824.1/09
DOMICILE INFORMATION ISSUED DATE Tanggal Dikeluarkan Keterangan Domisili
:
DOMICILE INFORMATION ISSUED BY Keterangan Domisili Dikeluarkan oleh
: Jakarta Selatan
DOMICILE INFORMATION EXPIRED DATE Masa Berlaku Keterangan Domisili
: 4 Juni 2010
KADIN CERTIFICATE NUMBER Nomor Sertifikat Kadin
: 20203.20084-6/08-12-1995
KADIN CERTIFICATE EXPIRED DATE Masa Berlaku Sertifikat Kadin
: 31 Desember 2009
DITJEN MIGAS CERTIFICATE
: 206/SKT/DU.4/DMT/208
1.601046.09.3171.1.00586 (Konsultan)
4 Juni 2009
Pemerintah Provinsi DKI Jakarta Kotamadya
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EMP EMP
Wisma Mulia 22nd Floor, Jl. Jend. Gatot Subroto Kav. 42, Jakarta 12710 Telephone: (62-21) 5290-6100; 5290-6200 Facsimile: (62-21) 5290-6300
NUMBER Nomor Sertifikat Ditjen Migas DITJEN MIGAS CERTIFICATE EXPIRED DATE Masa Berlaku Sertifikat Ditjen Migas
: 25 Maret 2010
OTHERS CERTIFICATES Sertifikat Lainnya
: INKINDO No. 0269/INKINDO/09/9/08
IV. PRODUCT AND/OR SERVICES IV. Produk dan/atau Jasa ACTIVITIES GROUP Sub Bidang Pekerjaan
:
1. Jasa Manajemen Proyek Terkait Konstruksi Industrial Plant dan Proses
2. Jasa Disain Enjiniring Mekanikal 3. Jasa Nasehat/Pra-Disain dan Disain Enjiniring Industrial Plant dan Proses
4. Jasa Nasehat/Pra-Disain dan Disain Enjiniring Bangunan
5. Jasa Nasehat/Pra-Disain dan Disain Enjiniring Pekerjaan Teknik Sipil Lainnya
6. 7. 8. 9. 10. DO YOU HAVE ANY BRAND NAMES AND TRADEMARKS? (FOR AGENT) Apakah Anda Mempunyai Merk Dagang?
:
1. N.A 2. 3. 4. 5.
DO YOU MANUFACTURE ANY PRODUCT? Apakah Anda Membuat Suatu Produk?
:
1. N.A 2. 3. 4. 5.
V. FINANCIAL OVERVIEW V. Ikhtisar Keuangan FINANCIAL CLASSIFICATION
:
M Page 5 of 7
EMP EMP
Wisma Mulia 22nd Floor, Jl. Jend. Gatot Subroto Kav. 42, Jakarta 12710 Telephone: (62-21) 5290-6100; 5290-6200 Facsimile: (62-21) 5290-6300
Klasifikasi Keuangan TAX PAYER ID/ NPWP Nomor Pajak/ NPWP BANK REFERENCE & ADDRESS Referensi Bank & Alamatnya
: :
01.742.627.1.016.000
1. PT.BANK NEGARA INDONESIA (Persero) Tbk. Kantor Cabang Utama Melawai Raya Jl. Melawai Raya No.1 Jakarta Selatan 12160 2.
VENDOR GUARANTEES DATA GIVEN ARE TRUE. VENDOR AGREES THAT EMP HAS THE RIGHT TO REJECT VENDOR APPLICATION WITHOUTEXPLAINING THE REASON OF REJECTION. Rekanan menjamin kebenaran data yang diberikan kepada EMP. Rekanan menyetujui bahwa EMP berhak menolak pendaftaran rekanan tanpa harus menyebutkan penyebab penolakan.
THIS STATEMENT OF DATA IS MADE WITH HONESTLY & CORRECTLY. I AGREED SANCTION WILL BE PLACED TO THE COMPANY THAT I CURRENTLY REPRESENTED IF IN THE FUTURE FINDS THAT MY STATEMENT OF DATA INCORRECTLY. Demikian data ini kami buat dengan sebenar-benarnya. Apabila keterangan dan pernyataan di atas tidak benar, saya setuju bahwa perusahaan yang saya wakili ini dikenakan sanksi. VENDOR CODE/USER NAME: Kode Rekanan/ Nama Pengguna:
: ENERKON Jakarta, 9 November 2009
Bambang Nugroho Gyat President Director
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EMP EMP
Wisma Mulia 22nd Floor, Jl. Jend. Gatot Subroto Kav. 42, Jakarta 12710 Telephone: (62-21) 5290-6100; 5290-6200 Facsimile: (62-21) 5290-6300
* Internal Use Only INPUT BY: Diisi Oleh:
........................
VERIFIED BY: Dibenarkan Oleh:
DCM Leader
APPROVED BY: Disetujui Oleh:
COI Committee Approval
Page 7 of 7
