For Main Company/Endorser

Annex 1

QUALIFICATION FORM

(For Main Company/Endorser)

Procurement: Hot Rolled Spring Steel Sup 7 Dia 20 mm of 600.000 Kg

The Owner ofthe Job:PTPindad(Persero)

The undersigned

Name:

Position/Fax:

Acting forand on behalf of[Name ofCompany]

Address:

Phone/Fax:

Statedthat:

I have a legal capacity to sign contracts in accordance ......

(according to companyregistration certificate/Power of Attorney)

I/the Company that I duly represented is not declaredin bankruptcy orits businessactivitiesare notbeing terminated/suspended nor being condemned for violence nor being under surveillance due to illegal activities by the Court.
I have neverbeen punished nor verdicted as guilty by any court in any competent jurisdiction due tomy/the company I duly represented professionalqualifications or illegal business activities.
I declared that I am not an employee of PT Pindad (Persero).
The Company thatIrepresentedis not includedin PT Pindad (Persero) or any other Corporate/Agencies’ blacklist.
The Company thatIrepresentedhave no record ofany breach of contracts due to lack of performances.
My company datais as follows:

Administration Data

A.1.General

1. / Company Name
2. / Status
3. / Address
Phone
Fax
E-mail
4. / Address / (filled inif the participant candidate isthe branchcompany)
Phone
Fax
E-mail

A.2Shares Ownership Structure

No. / Name / Identity Number / Capacity / Position in Company
1.
2.
3.

Board Of Directors/Executive Board/CompanyRepresentative:

No. / Name / Identity Number / Capacity / Position in Company
1.
2.
3.

A.3Legal Basisof Establishmentof the Company

1. / Deed of Establishment
Address
Phone
Fax
E-mail
2. / Deed of Establishment (Last Revised)
Address / (filled inif the participant candidate isthe branchcompany)
Phone
Fax
E-mail

A.4Trade Business License

1. / Business Field
2. / Number
3. / Validity Period
4. / Authorized Issuer

A.5Company Registration Certificate

1. / Business Field
2. / Number
3. / Validity Period
4. / Authorized Issuer

A.6Domicile License (If there is no Business Place License)

1. / Business Field
2. / Number
3. / Validity Period
4. / Authorized Issuer

A.7Business Place License (If there is no Domicile License)

1. / Business Field
2. / Number
3. / Validity Period
4. / Authorized Issuer

Financial Data

B.1.Financial Report for the Year Ended 31st December 2014

ASSET / LIABILITIES
I.
II.
III. / Current Assets
-Bank
-Account Receivable
-Supplies
-Work in progress
Total (a)
Fixed Assets
-EquipmentMachine
-Inventory
-Buildings
Total (b)
Other Assets (c) / IV.
V.
VI. / Short Term Liabilities
-Account Payable
-Tax Payable
-Others
Total (d)
Long Term Liabilities (e)
Equity
(a+b+c) – (d+e)
Total / Total

Short Term Receivable (within 6 (six) months):Rp/USD………………….

Long Term Receivable (more than six months):Rp/USD………………….

Total :Rp/USD………………….

B.2.Financial Report for the Year Ended 31st December 2015

Short Term Receivable (within 6 (six) months):Rp/USD………………….

Long Term Receivable (more than six months):Rp/USD………………….

Total :Rp/USD………………….

B.2Taxation

1. / Taxpayer Identification Number
2. / Annual Tax Return Number/Date – Latest Taxable Year
3. / Tax Payment Slip Number/Date – In Last 3 (three) Months
4. / Taxable Entrepreneur Confirmation Number
5 / Dated

C.Personnel Data

Personal In Charge (PIC) for all of theprocurement process.

No. / Name / Birth Date / Position in Company
1
2
..
..

D.Company Experiences in appropriate bussiness field in last 2 (two) years.

No / Procurement Name / Field / Location / Affiliate Company / Contract / Completed Date base on:
Name / Address/
Phone / Number/ Date / Value / Contract / Certificate of Acceptance
1
2
..
..

E.Work / Jobs Data That StillBeingCarried Out

No / Procurement Name / Field / Location / Affiliate Company / Contract / Completed Date base on Contract:
Name / Address/
Phone / Number/ Date / Value
1
2
..
..

IN WITNESS WHEREOF, this Qualification Formis filled and submitedwith full sense of responsibility.Ifthere are found any discrepancy/forgery in the futureon thedata/documents whichhas beensubmited, we are willing torecieveany administrativesanctions in accordance withthe applicableprovisions ofPTPindad(Persero) and recieve criminalsanctionsin accordance with thelaw and regulation of the Republic of Indonesia.

Sincerely,

______[place],[month] [date]2016

(Company name)

Seal ofRp6,000.

(Signature & companystamp)

(Full Name & Position/Capacity)

Annex 2

QUALIFICATION FORM

(For Endorsee)

Procurement: Hot Rolled Spring Steel Sup 7 Dia 20 mm of 600.000 Kg

The Owner ofthe Job:PTPindad(Persero)

The undersigned

Name:

Position/Fax:

Acting forand on behalf of[Name ofCompany]

Address:

Phone/Fax:

Under the Power of Attorney of [Main/Principal Company Name] as duly representative in the entire procurement process of PT Pindad (Persero).

Power of Attorney Number:

Power of Attorney Dated:

Statedthat:

I have a legal capacity to sign contracts in accordance ......

(according to companyregistration certificate/Power of Attorney)

I/the Company that I duly represented is not declaredin bankruptcy orits businessactivitiesare notbeing terminated/suspended nor being condemned for violence nor being under surveillance due to illegal activities by the Court.
I have neverbeen punished nor verdicted as guilty by any court in any competent jurisdiction due tomy/the company I duly represented professionalqualifications or illegal business activities.
I declared that I am not an employee of PT Pindad (Persero).
The Company thatIrepresentedis not includedin PT Pindad (Persero) or any other Corporate/Agencies’ blacklist.
The Company thatIrepresentedhave no record ofany breach of contracts due to lack of performances.
My company datais as follows:

Administration Data

A.1.General

1. / Company Name
2. / Status
3. / Address
Phone
Fax
E-mail
4. / Address / (filled inif the participant candidate isthe branchcompany)
Phone
Fax
E-mail

A.2Shares Ownership Structure

No. / Name / Identity Number / Capacity / Position in Company
1.
2.
3.

Board Of Directors/Executive Board/CompanyRepresentative:

No. / Name / Identity Number / Capacity / Position in Company
1.
2.
3.

A.3Legal Basisof Establishmentof the Company

1. / Deed of Establishment
Address
Phone
Fax
E-mail
2. / Deed of Establishment (Last Revised)
Address / (filled inif the participant candidate isthe branchcompany)
Phone
Fax
E-mail

A.4Trade Business License

1. / Business Field
2. / Number
3. / Validity Period
4. / Authorized Issuer

A.5Company Registration Certificate

1. / Business Field
2. / Number
3. / Validity Period
4. / Authorized Issuer

A.6Domicile License (If there is no Business Place License)

1. / Business Field
2. / Number
3. / Validity Period
4. / Authorized Issuer

A.7Business Place License (If there is no Domicile License)

1. / Business Field
2. / Number
3. / Validity Period
4. / Authorized Issuer

Financial Data

B.1.Financial Report for the Year Ended 31st December 2014

Short Term Receivable (within 6 (six) months):Rp/USD………………….

Long Term Receivable (more than six months):Rp/USD………………….

Total :Rp/USD………………….

B.2.Financial Report for the Year Ended 31st December 2015

Short Term Receivable (within 6 (six) months):Rp/USD………………….

Long Term Receivable (more than six months):Rp/USD………………….

Total :Rp/USD………………….

B.2Taxation

C.Personnel Data

Personal In Charge (PIC) for all of theprocurement process.

No. / Name / Birth Date / Position in Company
1
2
..
..

D.Company Experiences in appropriate bussiness field in last 2 (two) years.

No / Procurement Name / Field / Location / Affiliate Company / Contract / Completed Date base on:
Name / Address/
Phone / Number/ Date / Value / Contract / Certificate of Acceptance
1
2
..
..

E.Work / Jobs Data That StillBeingCarried Out

No / Procurement Name / Field / Location / Affiliate Company / Contract / Completed Date base on Contract:
Name / Address/
Phone / Number/ Date / Value
1
2
..
..

Sincerely,

______[place],[month] [date]2016

(Company name)

Seal ofRp6,000.

(Signature & companystamp)

(Full Name & Position/Capacity)

Annex 3

[Company Name, Address, Telephone, Fax, E-Mail]

LETTER OF INTENT THAT INTERESTED AND COMPETENT TO FOLLOW THE ENTIRE PROCUREMENT PROCESS

[Place, date]

No. [Letter Number]

As for : Letter Of Intent That Interested And Competent

To Follow The Entire Procurement Process

To:ProcurementCommitteeof PTPindad(Persero)

With respect;

The undersigned, [name of Director] as the duly authorized representative of [company name] as a participant candidate of Administration Selection. We confirm that we have understood and accept the contents of the Administrative Documents that has delivered to Procurement Committee of PTPindad(Persero).

We hereby declare interested and competent to follow the entire procurement process of Hot Rolled Spring Steel Sup 7 Dia 20 mm of 600,000 Kg.

In order toprovide information about the capabilities of our company infinancial,technical and experience, we have beensubmitted softcopy of ourQualification Formand other requirement documentsvia email to the Procurement Committee beforehand, to verified the authenticity of the documents.

In case ofdoubtorobscurityagaints thedocuments thatwesubmit, weare willingto be clarified and shall notchargesany claim against PTPindad(Persero) concerningclarification results.

We make thisdocuments with a fullsense ofresponsibilityandshall be binding inaccordance with theapplicable provisions of PT Pindad (Persero).

Sincerely,

______[place],[month] [date]2016

(Company name)

Seal ofRp6,000.

(Signature & companystamp)

(Full Name & Position/Capacity)

Annex4

[Company Name, Address, Telephone, Fax, E-Mail]

APPLICATION LETTER BECOME A PART OF PT PINDAD VENDOR LIST

[Place, date]

No. [Letter Number]

As for : Application Letter Become a Part of PT Pindad Vendor List

To:ProcurementCommitteeof PTPindad(Persero)

With respect;

The undersigned, [name ofDirector]as the duly authorized representative of [company name] concerning of procurement process in PT Pindad (Persero) to provide the Hot Rolled Spring Steel Sup 7 Dia 20 mm of 600,000 Kg.

We herebyexpresses the intent to join the procurement process by applied forbecoming aPartner ofPT Pindad(Persero),as consideration wesubmit the Qualification Formasattached toAnnex1.

In case ofdoubtorobscurityover thesubmitted documents, weare willingto be clarified.

We hopeto be abletobecomepartnersof PTPindad(Persero)and followthe entire procurement process.We shall notchargesany claim against PTPindad(Persero) concerningclarification results.

Sincerely,

______[place],[month] [date]2016

(Company name)

Seal ofRp6,000.

(Signature & companystamp)

(Full Name & Position/Capacity)

Annex 5

[Company Name, Address, Telephone, Fax, E-Mail]

LETTER OF INTENT OF THE COMPANY

[Place, date]

No. [Letter Number]

As for : Letter of Intent of the Company

To:ProcurementCommitteeof PTPindad(Persero)

With respect;

The undersigned, [name ofDirector]as the duly authorized representative of [company name], expresses the intent to join the procurement process in PT. Pindad (Persero) to provide the Hot Rolled Spring Steel Sup 7 Dia 20 mm of 600,000 Kg.

Stated :

That our companyis not being under surveillance due to illegal activities by the Court.
That our companyis not declaredin bankruptcy.
Thatourbusiness activitiesare not beingsuspended/terminated.
That the Directors as well asits powerof attorney of our companyare notbeing condemned for violence nor being under surveillance due to illegal activities by the Court.
That the Directors as well asits powerof attorney of our companydonothave anyconflict of interestinvolvingPTPindad(Persero).
Thatwe guaranteethat all ofProcurementDocumentsthat has been submittedto PT Pindad (Persero) is correct.
If weselected asProcurement Winners, weare ableto providethe goodsin accordance withthe specificationsset forth in theProcurementGuidelines.

Ifthere arefound any discrepancy/violation in the future on such statements above, then we are willing toreceive administrativesanctionsin accordance withthe applicableprovisions ofPTPindad(Persero) and wefullyfreedPTPindad(Persero)of claimin any formand/or fromany party.

Sincerely,

______[place],[month] [date]2016

(Company name)

Seal ofRp6,000.

(Signature & companystamp)

(Full Name & Position/Capacity)

Annex 6

INTEGRITY PACT

I, the undersigned, as the duly authorized representative of (Company Name) in order to participate in procurement of Hot Rolled Spring Steel Sup 7 Dia 20 mm of 600,000 Kg in PT Pindad (Persero), hereby declare that I’am:

Shall not, directly or through any other personcommit/involve in corruption,collusion and/ornepotism;
Shall reported to the authorities / authorities determine if there are indications ofcorruption,collusion and/ornepotism inthisprocurementprocess;
Shall carry out tasks in the entire procurementprocess ina clean, transparent andprofessional.
Shall useall of thecapabilities and resourcesoptimallyto deliverthe bestresultin the entire procurement process;

IfI violate / break this Integrity Pact, I’amwilling to receive any administrativesanctions andmoralsanctionsas wellas criminalsanctions in accordance with thelaw and regulation of the Republic of Indonesia.

Sincerely,

______[place],[month] [date]2016

(Company name)

Seal ofRp6,000.

(Signature & companystamp)

(Full Name & Position/Capacity)

Annex 7

DOCUMENTS THAT MUST BE PROVEN AFTER THE FIRST VERIFICATION

Qualification Form(original)
Letter of Intent That Interested and Competent to Follow the Entire Procurement Process (original)
Application Letter to Become a Part of PT Pindad Vendor List(forparticipant candidateswho previouslyhave not registered / nevercooperated withPTPindad(Persero)) (original)
Letter of Intent that the participant candidate is not being under surveillance due to illegal activities by the Court, not declaredin Bankruptcy, its business activities not being suspended/terminated nor being condemned for violence, ect(original)
Integrity Pact(original)
Power of Attorney (For Participant Candidatewhich acting as the duly authorized representative of Other Companyespecially Foreign Companiestodo the entire procurementprocess) (original)
Non-small Trade Business License (SIUP) or other Business Licences in business field which appropriate with the object of this procurement, that issued by authorized government agencies which stillvalid (Copy)
Business PlaceLicense (SITU)or Domicile License, which stillvalid(Copy)
Company Profile (Copy)
Deed of Establishment (Copy)
Financial Report Audited in last 2 (two)fiscal year2014 and2015(Copy)
Tax Payment Slip in last 3 (three) month (Copy)
List of Composition Capital(Copy)
Organizational Structure(Copy)
List of procurement contracts that have been implemented in last 2 (two) year at Indonesia.
List ofprocurement contractsthat are currentlyin the process at Indonesia.
BankReference(Indonesian Bank) (original)

* Please drawn up the Documents based on the order specified above.

Annex 8

[Company Name, Address, Telephone, Fax, E-Mail]

LETTER OF PRICE QUOTATION

[Place, date]

No. [Letter Number]

As for : Letter of Price Quotation Of Hot Rolled Spring Steel Sup 7 Dia 20 mm of 600.000 kg

To :

VP ofIntegratedSupply Chain Division

Up.Head Of Procurement Department of Bandung Area

PT Pindad (Persero)

Jl. Gatot Subroto No. 517-40284 Bandung, Indonesia

We confirm that we have read, understood and accept the contents of the Procurement Guidelinesthat are part ofthe AuctionAnnouncementdated______. In accordance withProcurementGuidelines and Delivery Time weherebysubmit a quotationfor the procurement ofHot Rolled Spring Steel Sup 7 Dia 20 mm of 600.000 Kg,with the Quotation Price of(Currency)______(______(Currency)) includingCIF;and

This Quotationisvalid for(60) sixty calendar daysfrom the date ofsubmissions deadline.

In accordancewith the Procurement Guidelines, along with this letterwesubmit:

Quotation Bond(original andone (1)copy);
Detail of Quotation Price (original andone (1)copy);

We make this Quotation to be used properly in order to fulfill one of the requirements for the Procurement Process at PT Pindad (Persero).

Sincerely,

______[place],[month] [date]2016

(Company name)

Seal ofRp6,000.

(Signature & companystamp)

(Full Name & Position/Capacity)

Annex 9

DETAIL OF QUOTATION PRICE

For Procurement Participants from Indonesia:

No / Item / Quantity / Unit / Price/Unit / Total Price
1 / Hot Rolled Spring Steel Sup 7 Dia 20 mm / 600.000 6 / KG
Total Before VAT 10%
VAT 10%
Total After VAT 10%

The price is Franco PT Pindad’s (Persero) factory.

For Procurement Participants from the Overseas who gave the Power of Attorney to Indonesia Industry or Company:

No / Item / Quantity / Unit / Price/Unit / Total Price
1 / Hot Rolled Spring Steel Sup 7 Dia 20 mm / 600.000 6 / KG
Total Price

Priceis including Cost, Insurance and Freight (CIF)

Note :

Delivery Timeis ______business daysfrom the date ofPurchase Order issuance.
The goods shall be delivered graduallyuntil August 31st 2016in accordance with the needsof PTPindad(Persero).
In every stage ofthe goods deliveryareincluded:

Mill of Certificate
Certificate of Origin
Certificate of Inspection

______[place],[month] [date]2016

(Company name)

Seal ofRp6,000.

(Signature & companystamp)

(Full Name & Position/Capacity)