PT International Nickel Indonesia, Tbk

VENDOR REGISTRATION FORM

Incomplete Do not send this form until it is completed
Fields with * are mandatory / Field-field dengan tanda * wajib diisi

Nama Perusahaan *
Company Name * ###
USD (United States Dolla
Informasi Umum Perusahaan Incomplete AUD (Australian Dollar)
Company General Information
CAD (Canadian Dollar)
NPWP
Tax Registration Number (for indonesian based company) ###
Tanggal Berdiri *
Date of Establishment * ###
Preferensi Mata Uang *
Preferred Currency * ###
Tipe Pemasok *
Supplier Type * ###
Jenis Usaha *
Business Type * ###
Website Perusahaan
Company Website AQ (Antarctica)
AR (Argentina)
Informasi Alamat
Address Information AS (American Samoa)
AT (Austria)
Alamat Utama
Main Address Incomplete AU (Australia)
AW (Aruba)
Tipe Alamat *
Type of Address * ###
Alamat *
Address * ###
Kota/Kabupaten *
City/Municipal * ###
Provinsi
Province/County ###
Negara *
Country * ###
Kode Pos
Zip Code BF (Burkina Faso)
Personil *
Contact Person * ###
Telepon *
Telephone * ###
Telepone Selular
Cellular Phone BI (Burundi)
Fax
Facsimile BJ (Benin)
E-mail
E-mail BM (Bermuda)
BN (Brunei Darussalam)

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PT International Nickel Indonesia, Tbk

Alamat Alternatif
Alternate Address BO (Bolivia)
BR (Brazil)
Tipe Alamat
Type of Address Pabrik / Factory
Alamat
Address BT (Bhutan)
Kota/Kabupaten
City/Municipal BV (Bouvet Island)
Provinsi
Province/County BW (Botswana)
Negara
Country BY (Belarus)
Kode Pos
Zip Code BZ (Belize)
Personil
Contact Person CA (Canada)
Telepon
Telephone CC (Cocos (keeling) Islan
Telepone Selular
Cellular Phone CD (Congo, The Democr
Fax
Facsimile CF (Central African Repu
E-mail
E-mail CG (Congo)
CH (Switzerland)

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PT International Nickel Indonesia, Tbk

Informasi Klasifikasi
Classification Information CI (Cote D'ivoire)
Untuk informasi komoditas dibawah, silakan diisi dengan "Ya" HANYA pada komoditas yang dihasilkan perusahaan Anda.
For commodity information below, please fill with "Yes" ONLY on commodity that your company provides. CK (Cook Islands)
Komoditas
Commodity Incomplete ###
Explorasi
Exploration ###
CN (China)
Penginderaan Jarak Jauh
Remote Sensing ###
Survey dan Pemetaan
Survey and Mapping ###
Geofisik dan Geoteknik
Geophysics and Geotechnical ###
Pengeboran dan Sampling
Drilling and Sampling ###
Analisa Laboratorium
Laboratory Analysis ###
CY (Cyprus)
Pertambangan
Mining ###
DE (Germany)
Penebangan Pohon
Trees Cutting ###
Pengupasan and Pembongkaran Lapisan Penutup
Stripping and Over burden Removal ###
Pengangkutan/Transportasi
Hauling/Trucking ###
Penyaringan and Pembongkaran
Screening and Crushing ###
Reklamasi
Reclamation ###
Pengembangan Infrastruktur Pertambangan
Mine Infrastructure Development ###
EE (Estonia)
Peralatan Pabrik
Plant Equipment ###
EH (Western Sahara)
Peralatan Mekanikal
Mechanical Equipment ###
Peralatan Elektrikal/Instrumentasi
Electrical/Instrumentation Equipment ###
Manufaktur dan Fabrikasi
Manufacturing and Fabrication ###
Bangunan Pabrik
Plant Building ###
FJ (Fiji)
Bahan Bakar & Bahan Baku
Fuel & Oil and Raw Materials ###
FM (Micronesia, Federate
Bahan Kimia
Chemical Supply ###
Bahan Bakar Minyak
Fuel ###
Oli
Lubricants ###
Batubara
Coal ###
Silica and Electrode Paste
Silika dan Electrode Paste ###
GE (Georgia)

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PT International Nickel Indonesia, Tbk

Konstruksi & Konsultasi

Construction & Consultation ###
GH (Ghana)
Mekanikal
Mechanical ###
Elektrikal
Electrical ###
Penggalian dan Pemindahan Tanah
Mining and Earth Moving ###
Bangunan
Building ###
Manufaktur dan Fabrikasi
Manufacturing and Fabrication ###
Instalasi
Installation ###
Lumpur Bor and Pemeliharaan
Drilling Mud Supply and Maintenance ###
Besi Baja dan Sejenisnya
Steels ###
One Way Bags (untuk nikel)
One Way Bags (for nickel) ###
GU (Guam)
Konsultasi Lain-Lain
Other Consultation ###
GY (Guyana)
Pengolahan Data
Data Processing ###
Explorasi dan pembangunan
Exploration Development ###
Studi Kelayakan
Feasibility Study ###
Studi Sosial Ekonomi Lingkungan
Socio Economic of Environmental Study ###
Konstruksi Tambang
Mine Construction ###
Operasi Pertambangan
Mine Operation ###
Pengangkutan Tambang/Transportasi
Mine Hauling/Trucking ###
Penyaringan dan Pembongkaran
Screening/Crushing ###
Rehabilitasi Pertambangan/Reklamasi
Post Mining Rehabilitation/Reclamation ###
Manajemen Tambang
Mine Management ###
IO (British Indian Ocean
Lain-Lain
Others ###
IR (Iran, Islamic Republi
Sistem Telekomunikasi
Telecommunication System ###
Komputerisasi
Computerization ###
Jasa Boga dan Tata Graha
Catering, Foods, Beverages and Consumables ###
Jasa Penilai, Survei dan Kalibrasi
Assessors, Surveys and Calibration ###
Penanganan dan Manajemen Sampah
Handling and Waste Management ###
Jasa and Pemasok Energi Listrik
Power Supply and Services ###
Proteksi Pabrik and Sistem Sekuriti
Plant Protection and Security System ###
Bongkar Muat Kargo
Stevedoring and Cargo ###
Penyewaan Peralatan Berat dan Teknik
Heavy and Technical Equipment Rental ###
Peralatan Kantor
Office Supplies ###
Peralatan Rumah Tangga
Households ###
KP (Korea, Democratic P

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PT International Nickel Indonesia, Tbk

Others (If not listed above)

Lainnya (jika tidak ada diatas) ###

###

###

###
LA (Lao People's Democr
Informasi Usaha
Business Information Incomplete LB (Lebanon)
LC (Saint Lucia)
Lama tahun dalam bisnis *
Years in Business * ###
Tiga nama klien saat ini *
Name three current Clients * ###
Total Penjualan Tahunan *
Annual Sales Turn over * ###
LS (Lesotho)
Informasi E-Procurement
Business Information Incomplete ###
LU (Luxembourg)
Apakah Anda bertransaksi secara elektronik? *
Do you trade electronically? * LV (Latvia)
Jika ya, sistem apa yang Anda pergunakan?
If yes, what system are you using in? Ya / Yes
Sebutkan website untuk sistem tersebut
Name the website for that system MA (Morocco)
Jika tidak, apakah Anda bersedia untuk bertransaksi elektronik?
If no, are you willing to trade electronically? MC (Monaco)
MD (Moldova, Republic O
Informasi Bank & Pajak
Bank & Tax Information Incomplete MG (Madagascar)
MH (Marshall Islands)
Nama Bank Perusahaan *
Company's Bank * ###
Cabang Bank *
Bank Branch * ###
Alamat Bank *
Bank Address * ###
Status PPN (Pajak Pertambahan Nilai) *
VAT (Value Added Tax) Status * ###
Status Pembebasan Pajak *
Tax Exemption Status * ###
Tanggal Berakhirnya Pembebasan Pajak
Expiry Date for Tax Exemption MP (Northern Mariana Is
MQ (Martinique)

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PT International Nickel Indonesia, Tbk

Akreditasi Kualitas
Quality Accreditation MR (Mauritania)
MS (Montserrat)
Deskripsi Kualitas
Quality Description MT (Malta)
Otoritas Akreditasi
Accreditation Authority MU (Mauritius)
Nomor Sertifikat
Cerificate Number MV (Maldives)
Tanggal Efektif
Effective Date MW (Malawi)
Tanggal Berakhir
Expiry Date MX (Mexico)
MY (Malaysia)
Informasi Personil
People Information MZ (Mozambique)
NA (Namibia)
Pengisi Data ini
This data Filler Incomplete NC (New Caledonia)
NE (Niger)
Nama *
Name * ###
Posisi di Perusahaan *
Position in the Company * ###
Nomor Kontak *
Contact Number * ###
E-mail *
E-mail * ###
NO (Norway)
Direktur Utama/Penanggung Jawab Perusahaan
President Director/Company Representative Incomplete NP (Nepal)
NR (Nauru)
Nama *
Name * ###
Posisi di Perusahaan *
Position in the Company * ###
Nomor Kontak *
Contact Number * ###
E-mail *
E-mail * ###
PE (Peru)
Tanggal *
Date * ###
###

Saya menyatakan bahwa data-data yang diisi di atas adalah benar sepanjang pengetahuan saya. Saya menerima resiko PT Vale Indonesia, tbk membatalkan bisnis
dengan perusahaan saya jika saya ternyata memberikan data yang tidak benar. Saya juga menyatakan bahwa saya telah membaca dan mengerti ‘Business Conduct
Guidelines & Ethical Practices’ PT Vale Indonesia, tbk, serta akan mematuhinya jika PT Vale Indonesia, tbk melakukan bisnis dengan perusahaan saya.
PH (Philippines)
I hereby stated that all of the information provided above is correct and accept the risk that PT Vale Indonesia, tbk will cancel all business if this is not true. I also
stated that I have read and understood Business Conduct Guidelines & Ethical Practices of PT Vale Indonesia, tbk and will follow on that if PT Vale Indonesia, tbk
performing a business with my company.

* ###
PL (Poland)

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PT International Nickel Indonesia, Tbk

Lampiran
Attachment PM (Saint Pierre And Miq
Mohon lampirkan hal berikut dalam format PDF
Please PN (Pitcairn)
TDP / attach the following
SIUP / NPWP in PDF
/ Pendaftaran format (khusus perusahaan Indonesia)
Jamsostek
TDP / SIUP / NPWP / Jamsostek Registration) (Indonesian based company only) Mandatory PR (Puerto Rico)
Laporan Keuangan Terakhir
Latest Financial Statement Mandatory PS (Palestinian Territory,
Akta Perusahaan
Company Certificate Mandatory PT (Portugal)

SIUJP (hanya untuk perusahaan jasa dan berbasis di Indonesia) Mandatory PW (Palau)
SIUJP (only for services company based in Indonesia)
Informasi Produk
Product Information Optional PY (Paraguay)
Referensi
Reference Optional QA (Qatar)
Lain-lain yang relevan
Other as appropriate Optional RE (Reunion)
RO (Romania)
PT Vale Indonesia, tbk dapat meminta informasi lain sebelum memulai bisnis dengan Perusahaan Anda RU (Russian Federation)
PT Vale Indonesia, tbk may ask you to provide further information prior to conducting business with your company RW (Rwanda)
SA (Saudi Arabia)
SB (Solomon Islands)
SC (Seychelles)

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