Appendix 2

Tender Documents

BIDDER shall submit the Tender Documents, including any and all supporting documents,
required for COMPANYS’s evaluation as described below:

1. Bidder must submit Compliance Statement based on COMPANY draft.

2. Bidder must submit Company Information based on COMPANY draft.
3. Bidder must submit all supporting documents as stated in the Tender Document.
4. Bidder must submit VENDOR MASTER DATA FORM based on COMPANY draft.
5. Bidder must submit statement of integrity based on COMPANY draft.

Failure to submit the requested documents could disqualify the bidder.

Appendix 2
 TENDER DOCUMENT: Compliance Statement

1. Under and subject to the RFP hereto, the undersigned does hereby tender and offer to
execute and perform the Scope of Works and provisions and provide the facility and everything
of every kind respectively named, shown, described, and alluded to in, or to be inferred
from the tender including all its related appendices and other related documents, to be
executed and provided by the Bank for the described works in conformity with the said
Requirements.
2. The undersigned agrees to be bound by the Schedule of Rates.
3. The tender price shall be as listed in the Schedules of Rates.
4. The undersigned agrees to complete the Works as required by DSLNG throughout the duration
of the Contract period.
5. Whereas it is understood that DSLNG reserves the right to accept or refuse this tender for any
reason. The undersigned agrees that this tender shall remain valid and shall not be withdrawn
within ninety (90) days from the final date for submission of tenders.
6. The undersigned confirms, after personal scrutiny, that the documents used by the undersigned
in compiling this tender are true copies of the documents included in the tender documents.
7. The undersigned agrees that this tender is in full compliance with terms and conditions of the
reference agreement.

Name of Company: ...............................................................................................................

Address of Company: ...............................................................................................................
Full Name of Contractor: .............................................................................................................

Position in Company: ...............................................................................................................

E-mail: ...............................................................................................................
Office Phone: ...............................................................................................................
Mobile Phone: ...............................................................................................................
Fax: ...............................................................................................................
Date: ...............................................................................................................

Appendix 2
 TENDER DOCUMENT: Company Information

1. Company Data

Full Name of Company: .................................................................................

Address of main office: .................................................................................
Addresses of the branch(es): .................................................................................
Registered office address .................................................................................
Telephone number: .................................................................................
Fax number: .................................................................................
Contact Person .................................................................................
Name & Position .................................................................................

2. Company Status: Limited / Partnership / Others (Specify)

..........................................................................................................................

3. Parent Company:

a) Name and Address of Parent Company, if any:

..........................................................................................................................

b) Name and Address of Ultimate Parent Company, if any:

..........................................................................................................................

Appendix 2 – Tender Document

The following items shall also be submitted in pdf format:

1. An organization chart showing the company’s structure, including the position of

directors and key personnel.
2. A list of commercial branches of the company.
3. The company’s documents, namely:
 Copy of Deed of Establishment (Akta Perusahaan)
 Copy of Approval from Ministry of Justice
 Copy of Company Registration Number (Tanda Daftar Perusahaan)
 Copy of Tax Payer Identification Number (NPWP)
 Copy of Taxable Entrepreneur for VAT Purpose (Pengusaha Kena Pajak)
 Copy of NIB (Nomor Induk Berusaha)
 Copy of Membership Certificate (if any)
 QHSE POLICY
4. Company Profile.

Appendix 2 – Tender Document

VENDOR MASTER DATA FORM
No: ................................................................. (filled by DSLNG)

New Update Block Delete (filled by DSLNG)

Company Name ......................................................................................................................................................................................................

Address ......................................................................................................................................................................................................

Country ......................................................................................................................................................................................................

Phone ......................................................................................................................................................................................................

Contact Person ......................................................................................................................................................................................................

Sales Email Address …………………………………………………………………Mobile Phone ………….………………………………………………………………..

Finance Email Address ……………………………………………………………………………………………………………………. (Payment Notice Purpose)
Products/Services ......................................................................................................................................................................................................

......................................................................................................................................................................................................

Bank Name …………………………………………………………………. Branch Name …………………………………………………………..

Account Number ………………………………………………………………... Swift Code ……………………………………………………………….
IBAN ……………………………………………………………………….

Currency IDR SGD JPY KRW USD EUR GBP

Mandatory documents to be attached:
Article of Association/Deed of Establishment/Certificate of Incorporation (Akta Notaris)
Tax ID (NPWP)*
Taxable Entrepreneur Certificate (PKP) *
Company Registration ID (Tanda Daftar Perusahaan)
Company Profile
Statement of Integrity
Copy of Bank Account Statement Header
Other: ......................................................................................................................................................................................................

Remarks ............................................................................................................................................................................

Prepared by (Vendor) Checked by DSLNG Approved by DSLNG

Name:
Position: Procurement Support Procurement Manager

Date Date: Date:

*) For Indonesian Company only

Appendix 2 – Tender Document

PERNYATAAN INTEGRITAS/
STATEMENT OF INTEGRITY

Dengan ini kami menyatakan bahwa kami telah sepenuhnya membaca dan memahami Standar dan
Pedoman Nilai-Nilai Bagi Para Mitra Bisnis PT. Donggi Senoro LNG ("DSLNG") sebagaimana disampaikan
kepada kami.

Saya, sebagai Direktur/Wakil Direktur dari PT/CV/Firma ………………………………........, pada tanggal

Pernyataan Integritas ini adalah mitra bisnis DSLNG, dengan ini menyatakan bahwa kami setuju untuk
mendukung penerapan Pedoman Perilaku DSLNG, mematuhi hukum dan peraturan terkait, dan
menjunjung Standar dan Pedoman Nilai-Nilai Bagi Para Mitra Bisnis DSLNG tanpa kecuali.

Kami memahami bahwa konsekuensi dari ketidakpatuhan atau pelanggaran terhadap Standar dan
Pedoman Nilai-Nilai Bagi Para Mitra Bisnis yang diterapkan oleh DSLNG dan/atau hukum dan peraturan
terkait yang berlaku akan menjadi tanggung jawab kami dan kami mengetahui dan menerima bahwa
sanksi dan hukuman tertentu dapat dikenakan dalam hal terdapat pelanggaran dan/atau
ketidakpatuhan terhadap Standar dan Pedoman Nilai-Nilai Bagi Para Mitra Bisnis maupun hukum dan
peraturan terkait yang berlaku yang dapat berdampak kepada DSLNG baik langsung maupun tidak
langsung.

We hereby declare that we have fully read and understood the Values and Standards for Business
Partners of PT Donggi Senoro LNG ("DSLNG") as conveyed and disseminated to us.

I, as the authorized Director / Authorized Representative of PT/CV/Firma ........................................., on

the date of this Statement of Integrity is a registered business partner of DSLNG, hereby certify that we
agree to support the implementation of the DSLNG Code of Conduct, to comply with relevant laws and
regulations at all times, and to uphold the DSLNG Values and Standards for Business Partners without
exception.

We acknowledge that the consequences of non-compliance or violation of these applicable Values and
Standards for Business Partners and/or applicable laws and regulations shall be our responsibility and
we acknowledge and consent to the receive sanctions and/or penalties as our consequences should
such violations and/or non-compliance incurred and may be deemed to have either directly or indirectly
harmful consequences for DSLNG in any way.

Tanggal/Date:

Nama/Name:

-- End of Document --

Appendix 2 – Tender Document