First Pass Form

SECTION I

First Pass Form is require to be completed by our partner before on-boarded to

PT Brilliant Ecommerce Berjaya (Mbiz.co.id)
Information requirements:
1) Company
2) Parent/ Holding company / Group
3) Shareholders
4) BOC and BOD
5) Subsidiaries and affiliates company

COMPANY INFORMATION

Company Name: * PT. MERAH PUTIH 13

Country of INDONESIA
Incorporation: *

Date of
06 02 2014
Incorporation: *
Date Month Year
You can enter either the full date (dd/mm/yyyy) or
just the year (yyyy)
No NPWP: * 66.816.424.7-307.000
Previous Company
Names:
(If applicable)
Industry Sector:

ADDRESS INFORMATION

Address: * JL. HANG TUAH NO. 12 A RT. 25 RW. 009

City: PALEMBANG

Country: INDONESIA
Additional
Comments:
 First Pass Form
* Required fields
PARENT / HOLDING COMPANY INFORMATION

Company Name: *

Country of
Incorporation: *

Date of
Incorporation: *
Date Month Year
You can enter either the full date (dd/mm/yyyy) or
just the year (yyyy)
Previous Company
Names:
(If applicable)
Industry Sector:

ADDRESS INFORMATION

Address: *
City:

Country:
Additional
Comments:

* Required fields
 First Pass Form

PERSONAL INFORMATION
SHAREHOLDERS
Person Name: * 1. DIDI Surname/ First
ZULKA * Names/
RNAIN Last Other
2. ERICH Name Names
FERDI
ANSYA
H
Personal Title: SIR
(e.g. Dr, Professor or Sir)
Business Title:
Gender: Male Female Unknown

Date of Birth:

13 01 1975
21 10 1981
Date Month Year
You can enter either the full date (dd/mm/yyyy) or just
the year (yyyy)
Aliases: 1. DIDI Surname/ First
2. ERICH Last Names/
Name Other
Names
Passport No.:
Other ID Numbers:
Citizenship:

ADDRESS INFORMATION

Address: 1. PERUM GRIYA SENANG HATI NO. 15

2. PERUM GRIYA SENANG HATI BLOK F NO . 8

City: PALEMBANG
 First Pass Form

Country: INDONESIA

Additional
Comments:

* Required fields
PERSONAL INFORMATION
(BOARD OF COMMISSIONERS AND DIRECTORS)
Person Name: * 1. DIDI Surname/ First
ZULKA * Names/
RNAIN Last Other
2. ERICH Name Names
FERDI
ANSYA
H
Personal Title: SIR
(e.g. Dr, Professor or Sir)
Business Title:
Gender: Male Female Unknown

Date of Birth:

13 01 1975
21 10 1981
Date Month Year
You can enter either the full date (dd/mm/yyyy) or just
the year (yyyy)
Aliases: 1. DIDI Surname/ First
2. ERICH Last Names/
Name Other
Names
Passport No.:
Other ID Numbers:
Citizenship:
 First Pass Form
ADDRESS INFORMATION

Address: 1. PERUM GRIYA SENANG HATI NO. 15

2. PERUM GRIYA SENANG HATI BLOK F NO. 8
City: PALEMBANG

Country: INDONESIA

Additional
Comments:

* Required fields

COMPANY INFORMATION
(SUBSIDIARIES AND/OR AFFILIATED COMPANY)
Company Name: *

Country of
Incorporation: *

Date of
Incorporation: *
Date Month Year
You can enter either the full date (dd/mm/yyyy) or
just the year (yyyy)
Previous Company
Names:
(If applicable)
Industry Sector:

ADDRESS INFORMATION

Address: *
 First Pass Form
City:

Country:
Additional
Comments:

* Required fields

SECTION II

VENDOR CONTACT PERSON INFORMATION

Contact Person
Name 1:
Contact Person
Phone 1:
Contact Person
Email 1:
Contact Person
Name 2:
Contact Person
Phone 2:
Contact Person
Email 2:

PAYMENT INFORMATION
Bank name and BANK RAKYAT INDONESIA (BRI) CABANG SRIWIJAYA
branch:
Bank account 0342-01-000591302
number:

BRANCH INFORMATION
Address:
Telephone:
 First Pass Form
Fax number:
Contact Person
Name:
Contact Person
Phone:
Contact Person
Email:

SERVICE LOCATION
No Product Produc Type of Address Telephone PIC
Category t& Service
Brand
1
2
3
4
5

VENDOR TEAM INFORMATION

No Division PIC Telephone Email
1 Sales
2 Finance
3 Purchasin
g
4 Warehous
e
5 Marketing
6 Service &
Support