Form Isian Penilaian Kualifikasi (Form PQ-001)-PTK007REV2 TATELY

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Format isian kualifikasi yang digunakan oleh kontraktor pada saat tahap prakualifikasi tender khususnya di perusahaan migas dalam ms word.
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  FORMULIR ISIAN PENILAIAN KUALIFIKASIQUALIFICATION EVALUATION FORM (BASED ON PEDOMAN TATA KERJA NO. 007-REVISI-II/PTK/I/2011 TENTANG PEDOMANPENGELOLAAN RANTAI SUPLAI KONTRAKTOR KONTRAK KERJA SAMA)(FORM PQ-001)  Fo! #$ I%$&' P'$#&$&' K &#$$*&%$/ Qualification Evaluation Form  No Pengadaan/  Bid No. :________________________________________________________________ Pengadaan/  Provision  :________________________________________________________________ Proyek/Unit Kerja/Project :________________________________________________________________ Kontraktor KKS/PSC :________________________________________________________________ Yang bertandatangan dibawah ini/ The undersigned:  Nama/  Name  :________________________________________________________________ Jabatan/  Position  :________________________________________________________________ Bertindak untuk dan ata nama /  As representative for  P!/Ko erai/ Company  :________________________________________________________________ #$amat/  Address :________________________________________________________________  ________________________________________________________________ !e$e on/  Phone :________________________________________________________________ %akimi$i/  Facsimile :________________________________________________________________ #$amat Sure$/&mai$ id:________________________________________________________________ 'enyatakan dengan ebenarnya bahwa/(ereby tru$y re reent: 1. Saya ecara hukum mem unyai ka aita menandatangani Perjanjian berdaarkan urat/  I legally have anauthoriation to sign the Agreement according to: !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!..!.  )euai akte endirian dan erubahannya/urat kuaa* ebutkan nomor dan tangga$ akte endirian dan  erubahannya/urat kuaa dan tangga$nya/ in line ith notarial document and its amendments#authoriation letter$ please state the notarial documents and its amendments#authoriation letter num%er and date + &. Saya dan/atau Peruahaan yang diwaki$i tidak edang dinyatakan ai$it atau kegiatan uahanya tidak edangdihentikan atau tidak edang menja$ani anki idana atau edang da$am engawaan engadi$an/  I and#or therepresentative Company is not in %an'rupt state or the %usiness activities is not on hold or not under a criminal  sanction or under court supervision.(. Saya tidak ernah dihukum berdaarkan utuan engadi$an ata tindakan yang berkaitan dengan kondite  ro,eiona$ aya/  I have never %een convicted %y the court for an act relation to my professional activities.). Saya dan/atau Peruahaan yang diwaki$i tidak me$akukan dan tidak akan ter$ibat da$am: era$atan yang ditawarkanuntuk !ender ini tidak berada di bawah ita jaminan dan/atau tidak ter$ibat roe $itigai dan/atau tidak ter$ibat da$amtuntutan dan/atau engketa hukum dan/atau ere$iihan dengan ihak ketiga mana un- raktek. raktek mono o$i-  eraingan tidak ehat- menggunakan barang i$$ega$- dan me$anggar etika bini/  I and#or the representativeCompany is and ill not %e involved in: pending liens against e*uipment to %e utilied for this Tender and#nor pending litigation process and#nor is %eing involved in any claim+ suit+ dispute ith any other third party+ monopolistic acts+unhealthy competition+ illegal material usage+ and violation to %usiness ethics   A. D&+&-,&+& %&&/ %&&&' %&& &,&#& %&&$ $* +/M ,&+&/! o!&' &% %+&+, #o34 1. Umum0Nama )P!/K1P&2#S3+4StatuPuat atau Cabang  5#$amat No !e$  No %a6&mai$7#$amat Kantor Puat No !e$  No %a6&mai$)diii- da$am ha$ yang menawar cabang eruahaan/bukan eruahaan  uat+  B. A,!$'$%+&+$o' D&+& 0 Buine Permit/  I,in -saha  No SK! '38#S:!angga$/  ate :'aa Ber$aku/ /alidity Period  :Penerbit 39in Uaha/  Permit  Issued %y : NoSK! Com any:!angga$/  ate :'aa Ber$aku/ /alidity Period  :Penerbit 39in Uaha/  Permit  Issued %y : No Surat Keterangan omii$i/ /alid omicilie  No. :!angga$/  ate :'aa Ber$aku/ /alidity Period  :Penerbit 39in Uaha/  Permit  Issued %y :  Jamotek Certi,icate/  0ertifi'at amsoste'  :!angga$/  ate :'aa Ber$aku/ /alidity Period  :Penerbit 39in Uaha/  Permit  Issued %y : No S3UP/S3U3:!angga$/  ate :'aa Ber$aku/ /alidity Period  :Penerbit 39in Uaha/  Permit  Issued %y : No S3UJK:!angga$/  ate :'aa Ber$aku/ /alidity Period  :Penerbit 39in Uaha/  Permit  Issued %y : No S3UP#;:!angga$/  ate :'aa Ber$aku/ /alidity Period  :Penerbit 39in Uaha/  Permit  Issued %y : No !P:!angga$/  ate :'aa Ber$aku/ /alidity Period  :Penerbit 39in Uaha/  Permit  Issued %y :4 ;andaan (ukum Pendirian Peruahaan/  2egal Foundation 3sta%lishment   #kte Pendirian Peruahaan/ Company Notary eeds
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