Formulir JK 2014
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NOMOR SERI FORMULIR
NOMOR REGISTRASI LPJK
FORMULIR PERMOHONANREGISTRASI SBU JASA PERENCANA / PENGAWAS KONSTRUKSI
KUALIFIKASI KEMAMPUAN KOMPETENSI
SUB KUALIFIKASI : UMUM
SPESIALIS
PENGISIAN FORMULIR DALAM MENETAPKAN KLASIFIKASI DAN KUALIFIKASI BADAN USAHA
DIGUNAKAN SELF ASSESMENT / PENILAIAN SENDIRI
KEBENARAN DATA BADAN USAHA MENJADI TANGGUNG JAWAB BADAN USAHA
DAN ASOSIASI PADA TINGKAT CABANG DIMANA BADAN USAHA TERDAFTAR
NAMA BADAN USAHA : ……………………………………………………..
ASOSIASI : ……………………………………………………..
PROPINSI : ……………………………………………………..
Formulir ini disiapkan oleh Asosiasi
Lembaga Pengembangan Jasa Konstruksi(Construction Services Development Board)
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Diisi oleh LPJK
FORMULIR PERMOHONANREGISTRASI SBU JASA PERENCANA / PENGAWAS KONSTRUKSI
KUALIFIKASI KEMAMPUAN KOMPETENSI
PENGISIAN FORMULIR DALAM MENETAPKAN KLASIFIKASI DAN KUALIFIKASI BADAN USAHA
DIGUNAKAN SELF ASSESMENT / PENILAIAN SENDIRI
KEBENARAN DATA BADAN USAHA MENJADI TANGGUNG JAWAB BADAN USAHA
DAN ASOSIASI PADA TINGKAT CABANG DIMANA BADAN USAHA TERDAFTAR
……………………………………………………..
……………………………………………………..
……………………………………………………..
LAMPIRAN 8
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NOMOR SERI FORMULIR NAMA ASOSIASI :
FORMULIR PERMOHONAN REGISTRASI
1 Nama Badan Usaha : ……………………………………….2 Bentuk Badan Usaha ( PT , CV dll ) : ……………………………………….3 Tanggal, Bulan, Tahun didirikan dalam Akta : ……………………………………….4 Propinsi tempat didirikan : ……………………………………….5 Alamat Badan Usaha : ……………………………………….
: ……………………………………….: ……………………………………….
Kode area Nomor telepon6 Nomor Telepon Badan Usaha :7 Nomor Fax.Badan Usaha : ……………………………………….8 E-mail Badan Usaha : ……………………………………….9 Situs Badan Usaha : ……………………………………….
10 Nomor Hand Phone yang dapatdihubungi :
11 NPWP . . . . .12 Keanggotaan badan usaha dari asosiasi lain 1 : ……………………………………….
2 : ………………………………………. 3 : ……………………………………….
4 : ……………………………………….
DIISI OLEH LPJK
Isikan dan cek 6 digit Kode Registrasi pada Sertifikat Badan Usaha lamaJenis Usaha Kode propinsi No. Registrasi BU
Tanda tangan dan nama jelas Petugas LPJK yg meregistrasi
…………………………..
LAMPIRAN 8- 1
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-
DIISI OLEH LPJK
Tanda tangan dan nama jelas Petugas LPJK yg meregistrasi
…………………………..
LAMPIRAN 8- 1
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Nomor : …………………….., 20..Lampiran :
Kepada YthDirektur Eksekutif LPJKN/Manager Eksekutif LPJK Provinsi*)
di ………………….
Perihal : Permohonan Registrasi Badan Usaha
Dengan hormat,
Dengan ini kami mengajukan permohonan mendapatkan Sertifikat Badan Usaha (SBU) sesuai usaha pada badan usaha kami sebagai berikut :
No Klasifikasi Sub Klasifikasi No Kode SubKualifikasi Keterangan
12 3 4 5
dst
Bersama ini kami lampirkan berkas - berkas dokumen pendukung yang dipersyaratkan dalam Peraturan LPJK Nasional :
....................................................
Demikian permohonan kami dan atas perkenan Saudara kami ucapkan terima kasih.
Pemohon, *)
PT / CV . ………………………….Direktur Utama / Penanggung Jawab
Badan Usaha
(......................................................) Tanda tangan dan nama jelas
Catatan : *) Pemohon harus ditanda tangani oleh Direktur Utama / Penanggung Jawab Badan Usaha
KEPALA SURAT BADAN USAHA
LAMPIRAN 8- 2
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…………………….., 20..
Dengan ini kami mengajukan permohonan mendapatkan Sertifikat Badan Usaha (SBU) sesuai usaha pada badan usaha kami sebagai berikut :
LAMPIRAN 8- 2
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Nomor : …………………….., 20..Lampiran :
Kepada YthDirektur Eksekutif LPJKN/Manager Eksekutif LPJK Provinsi*)
di ………………….
Perihal : Permohonan Klasifikasi dan Kualifikasi
Dengan hormat,
Dengan ini kami mengajukan permohonan Klasifikasi dan Kualifikasi sesuai usaha pada badan usaha kami sebagai berikut :
NoSBU YANG SUDAH DIMILIKI PERMOHONAN KONVERSI
Klasifikasi Sub Klasifikasi No Kode SubKualifikasi Klasifikasi Sub Klasifikasi No Kode SubKualifikasi12 3 4 5
dst
Bersama ini kami lampirkan berkas - berkas dokumen pendukung yang dipersyaratkan dalam Peraturan LPJK Nasional :
....................................................
Demikian permohonan kami dan atas perkenan Saudara kami ucapkan terima kasih.
Pemohon, *)
PT / CV . ………………………….Direktur Utama / Penanggung Jawab
Badan Usaha
(......................................................) Tanda tangan dan nama jelas
Catatan : *) Pemohon harus ditanda tangani oleh Direktur Utama / Penanggung Jawab Badan Usaha
KEPALA SURAT BADAN USAHA
LAMPIRAN 8- 3
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…………………….., 20..
Dengan ini kami mengajukan permohonan Klasifikasi dan Kualifikasi sesuai usaha pada badan usaha kami sebagai berikut :
Keterangan
Pemohon, *)
PT / CV . ………………………….Direktur Utama / Penanggung Jawab
Badan Usaha
(......................................................)
LAMPIRAN 8- 3
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SURAT PERNYATAANBADAN USAHA
Yang bertanda tangan di bawah ini :
Nama : ……………………………..……………………………..Alamat : ……………………………..……………………………..
……………………………..……………………………..Telepon : ……………………………..……………………………..Jabatan : Direktur Utama / Penanggung Jawab Badan Usaha Nama Ibu Kandung : ……………………………..……………………………..
menyatakan dengan sesungguhnya bahwa :
1 segala data dalam dokumen yang kami berikan adalah benar;2345 bilamana dikemudian hari terdapat permasalahan terkait perpajakan dan hukum, sepenuhnya menjadi tanggung jawab kami.
Demikian pernyataan ini dibuat dengan sesungguhnya.
………………….. 20..PT / CV ………………………
Direktur Utama / Penanggung JawabBadan Usaha
(..............................................)
Tanda tangan dan nama jelas
kami akan mematuhi segala ketentuan kode etik asosasi, ketentuan asosiasi dan LPJK serta peraturan perundangan yang berlaku, dan bersedia dikenakan sanksi bilamana kami melanggarnya;apabila dikemudian hari, ditemui bahwa dokumen - dokumen yang telah kami berikan tidak benar, maka kami bersedia dikenakan sanksi dan dimasukkan pada Daftar Sanksi Badan Usaha dan atau dikeluarkan dari Daftar Registrasi Badan Usaha;bilamana badan usaha kami dikenakan sanksi atas hal-hal tersebut butir 1, 2 dan 3 maka kami akan menerima ketentuan yang ditetapkan termasuk diumumkan melalui situs asosiasi dan LPJK.
Materaisesuai ketentuandan capbadan usaha
KEPALA SURAT BADAN USAHA
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SURAT PERNYATAANBADAN USAHA
segala data dalam dokumen yang kami berikan adalah benar;
bilamana dikemudian hari terdapat permasalahan terkait perpajakan dan hukum, sepenuhnya menjadi tanggung jawab kami.
………………….. 20..PT / CV ………………………
Direktur Utama / Penanggung JawabBadan Usaha
(..............................................)
Tanda tangan dan nama jelas
kami akan mematuhi segala ketentuan kode etik asosasi, ketentuan asosiasi dan LPJK serta peraturan perundangan yang apabila dikemudian hari, ditemui bahwa dokumen - dokumen yang telah kami berikan tidak benar, maka kami bersedia dikenakan sanksi dan dimasukkan pada Daftar Sanksi Badan Usaha dan atau dikeluarkan dari Daftar Registrasi Badan Usaha;bilamana badan usaha kami dikenakan sanksi atas hal-hal tersebut butir 1, 2 dan 3 maka kami akan menerima ketentuan
LAMPIRAN 8- 4
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FORMULIR ISIAN PERMOHONAN REGISTRASI BADAN USAHA
JASA PERENCANA / PENGAWAS KONSTRUKSI
I . DATA ADMINISTRASI
No. Urut Pendaftaran LPJK Diisi oleh petugas LPJK
No. seri : ………………………. ASOSIASI Diisi oleh petugas Asosiasi
A UMUM
1 Nama Badan Usaha Bentuk Badan Usaha : PT / CV /2 Alamat Badan Usaha
Kode pos3 Kabupaten / Kota4 Propinsi 5 Nomor Telepon , FaxB LANDASAN HUKUM No.Akte Kota
a. Akte Pendirian asli *) b. Akte Perubahan Terakhir 1 *) c. Akte Perubahan Terakhir 2 *) d. Akte Perubahan Terakhir 3 *) e. Akte Perubahan Terakhir 4 *)
2 Pengesahan Badan Usaha oleh Instansi berwenang Nomor a. Pendaftaran akta di Pengadilan Negeri *) b. Pengesahan akta pendirian oleh Menteri Kehakiman*) c. Pengumuman dalam Berita Acara Negara (untuk PT *)
3 NPWP *) - - - 4 Keanggotaan Asosiasi *) Nama Asosiasi Nomor Anggota
1 …………………………………………………. ………………………………………………….2 …………………………………………………. ………………………………………………….3 …………………………………………………. ………………………………………………….
5 Izin bagi Penanaman Modal *) Nomor Izin tetap …………………………………………………………………………………………….Tgl Pengeluaran izin ………………………………………………….
6 Masa laku SBU berakhir Tgl ……..bulan …. Tahun …… NO Registrasi SBU
Lampirkan rekaman SBU
*) Lampirkan bukti-bukti pendukung
LAMPIRAN 8- 5
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**) Bagi Badan Usaha cabang tidak perlu mengisi formulir ini cukup menggunakan sertifikat kantor pusat
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FORMULIR ISIAN PERMOHONAN REGISTRASI BADAN USAHA
JASA PERENCANA / PENGAWAS KONSTRUKSI
Tanggal
Tanggal
Nomor Anggota
LAMPIRAN 8- 5
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DATA PENGURUS
1A. Komisaris
No NAMA ALAMAT NO NPWP
12345
No NAMA **) ALAMAT NO NPWP
12345
*) Lampirkan fotocopy KTP
**) Lampirkan Surat Pernyataan bukan Pegawai Negeri dan Lampirkan Daftar Riwayat Hidup
Nama dan data Komisaris dan Direksi tercantumpada akte perubahan terakhir
B. Direksi / Pimpinan / Penanggung Jawab
LAMPIRAN 8 - 6
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DATA PENGURUS
A. Komisaris
NOMOR KTP *)
NOMOR KTP *)
LAMPIRAN 8 - 6
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2
No Klasifikasi NAMA **) ALAMAT 1.
D. Data Penanggung Jawab Klasifikasi (PJK)No Klasifikasi NAMA **) ALAMAT 1 12 23 34 45 5
No NAMA **) ALAMAT NRKA/NRKT*) KUALIFIKASI PEKERJAAN
1 2 3 4 5 6 7 8 9
10 3 Data Sumber Daya Manusia 1 Pendidikan S2 -tek S1-tek D3-tek STM S1 non tek D3 non tek
2 Jumlah
*) Lampirkan fotocopy KTP
**) Lampirkan Surat Pernyataan bukan Pegawai Negeri Sipil dan Lampirkan Daftar Riwayat Hidup
***) NPWP untuk PJT kualifikasi kecil tidak diwajibkan
Bila tidak cukup gunakan tambahan formulir dan kelompokkan dalam bidang
C. Data Penanggung Jawab Teknik (PJT)
E. Data Tenaga Teknik Ahli / Terampil / Non Teknik
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NPWP ***) NRKA
D. Data Penanggung Jawab Klasifikasi (PJK)NPWP ***) NRKA
KUALIFIKASI PEKERJAAN
SLTA Lain-lain
LAMPIRAN 8 - 7
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SURAT PERNYATAANBukan sebagai Pegawai Negeri Sipil
Yang bertanda tangan di bawah ini :
Nama : ……………………………..………………………..Tempat dan tgl lahir : ……………………………..………………………..Alamat : ……………………………..………………………..
Jabatan dalam Badan Usaha : ………………………..……………………………..
Nama : ……………………….……………………………..Alamat : ……………………….……………………………..
……………………….……………………………..
Demikian pernyataan ini dibuat untuk dipergunakan sebagaimana mestinya.
......................... 20..
Yang menyatakan PJBU/PJT/PJK *)
( ……………………. )
Tanda tangan dan nama jelas
* Diisi oleh Direksi / Penanggung Jawab Badan Usaha /Penanggung Jawab Teknis/Penanggung Jawab Klasifikasi dan Tenaga Teknik
* Khusus untuk Penanggung Jawab Teknik dan Klasifikasi wajib diketahui oleh Direktur Utama/ Penanggung Jawab Badan Usaha
Dengan ini menyatakan sesungguhnya bukan / tidak menjabat sebagai pegawai negeri sipil dan benar bekerja penuh waktu sebagai …………………... *) pada Badan Usaha :
LAMPIRAN 8 - 8
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SURAT PERNYATAANBukan sebagai Pegawai Negeri Sipil
......................... 20..
Yang menyatakanPJBU/PJT/PJK *)
( ……………………. )
Tanda tangan dan nama jelas
* Diisi oleh Direksi / Penanggung Jawab Badan Usaha /Penanggung Jawab Teknis/Penanggung Jawab Klasifikasi dan Tenaga Teknik
* Khusus untuk Penanggung Jawab Teknik dan Klasifikasi wajib diketahui oleh Direktur Utama/ Penanggung Jawab Badan Usaha
Dengan ini menyatakan sesungguhnya bukan / tidak menjabat sebagai pegawai negeri sipil dan benar bekerja penuh waktu
LAMPIRAN 8 - 8
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DATA KEUANGAN
1. Susunan Pemilikan saham
No. Nama Pemilik saham Alamat Saham Modal ( Rp )
dan No KTP * Jumlah lbr Nilai Rp Total Rp Presentasi (%) Dasar
1 2 3 4 5 6 7 8
JUMLAH 100%
* Lampirkan rekaman dan gunakan Formulir sendiri
2. Lampirkan SPT PPH badan 2 tahun terakhir ................., tanggal ...............
PT/CV. ...................................
Direktur Utama/Penanggung
Jawab Badan Usaha
Tanda tangan dan nama jelas
** Bagi Badan Usaha yang telah Go Publik/ Milik Negara Formulir isian disesuaikan sendiri
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DATA KEUANGAN
Modal ( Rp )
Disetor Presentasi (%)
9 10
%
................., tanggal ...............
PT/CV. ...................................
Direktur Utama/Penanggung
Jawab Badan Usaha
Tanda tangan dan nama jelas
LAMPIRAN 8-9
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NERACA BADAN USAHA Per 31 DESEMBER Tahun "N"
(dalam ribuan rupiah)AKTIVA
NO. TAHUN "N" TAHUN "N-1" NO.
I. AKTIVA LANCAR Rp .......... Rp .......... I. KEWAJIBAN LANCAR
1 Kas dan Bank Rp .......... Rp .......... 1 Utang Usaha
2 Piutang Usaha Rp .......... Rp .......... 2 Utang Bank (Jangka Pendek)
3 Persediaan Rp .......... Rp .......... 3 Uang Muka Proyek
4 Piutang Pajak Rp .......... Rp .......... 4 Utang Pajak
5 Biaya dibayar dimuka Rp .......... Rp .......... 5 Biaya Yang Masih Harus Dibayar
6 Pekerjaan Dalam Proses Rp .......... Rp .......... 6 Utang Jangka Panjang Yang sudah Jatuh Tempo
TOTAL AKTIVA LANCAR (a) Rp .......... Rp .......... 7 Utang Lainnya
TOTAL KEWAJIBAN LANCAR (d)
II. KEWAJIBAN JANGKA PANJANG (e)
II. AKTIVA TETAP Rp .......... Rp .......... 1 Utang Bank (Jangka Panjang)
1 Peralatan Proyek Rp .......... Rp .......... 2 Utang Lainnya
2 Inventaris Rp .......... Rp ..........
3 Peralatan Lainnya Rp .......... Rp .......... III MODAL
4 Komulasi Penyusutan Rp .......... Rp .......... 1 Modal Disetor
TOTAL AKTIVA TETAP (b) Rp .......... Rp .......... 2 Selisih "Penilaian Kembali" Aktiva Tetap
3 Laba Ditahan
III. Aktiva lainnya ( c ) Rp .......... Rp ..........
TOTAL AKTIVA Rp .......... Rp .......... TOTAL KEWAJIBAN DAN MODAL
Total Kekayaan Bersih = Modal Disetor + Selisih Penilaian Kembali Aktiva Tetap + Laba Ditahan
................., tanggal ...............
PT/CV. ................................... Direktur Utama/Penanggung
Meterai Jawab Badan Usaha
sesuai ketentuan
dan CapBadan Usaha
Tanda tangan dan nama jelas
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NERACA BADAN USAHA Per 31 DESEMBER Tahun "N"
(dalam ribuan rupiah)PASIVA
TAHUN "N" TAHUN "N-1"
Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
Rp .......... Rp ..........
LAMPIRAN 8-10
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III.A DATA TENAGA KERJA
PJT
Nama ( Lengkap ) Tempat Pendidikan akhir *) PengalamanNo Hanya untuk Tenaga Teknik yang Tgl Lahir dan No. Ijasah NRKA Kerja di bidangnya
dipersyaratkan sebagai PJT (Tahun )1 2 3 4 5 6
PJK Nama ( Lengkap ) Tempat Pendidikan akhir *) Pengalaman
No Hanya untuk Tenaga Teknik yang Tgl Lahir dan No. Ijasah NRKA Kerja di bidangnya dipersyaratkan sebagai PJK (Tahun )
1 2 3 4 5 6
Tenaga Ahli TetapNama ( Lengkap ) Tempat Pendidikan akhir *) Pengalaman
No Hanya untuk Tenaga Teknik yang Tgl Lahir dan No. Ijasah NRKA Kerja di bidangnya dipersyaratkan sebagai PJK (Tahun )
1 2 3 4 5 6
1 Formulir ini hanya digunakan utk tenaga teknik sbg Penanggung Jawab Direktur Utama / Penanggung JawabBadan Usaha /Direksi dan Penanggung jawab klasifikasi/penanggung jawab teknik Badan Usaha
2 Lampirkan rekaman ijasah terakhir, dan Sertifikat pelatihan, *)3 Lampirkan surat perikatan tenaga teknik 4 Lampirkan NRKA/NRTK untuk tenaga teknik dilengkapi dengan surat pernyataan Tanda tangan dan nama jelas
tenaga teknik, serta daftar riwayat hidup lengkap dng riwayat pekerjaan
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III.A DATA TENAGA KERJA
PJT
Status dlm Badan Usaha sbg Direksi/Penanggung
Jawab Teknik / Klasifikasi/Tenaga Ahli tetap7
PJK Status dlm Badan Usaha sbg Direksi/Penanggung
Jawab Teknik / Klasiikasi/Tenaga ahli Tetap7
Tenaga Ahli TetapStatus dlm Badan Usaha sbg Direksi/Penanggung
Jawab Teknik / Klasiikasi/Tenaga ahli Tetap7
Direktur Utama / Penanggung JawabBadan Usaha
Tanda tangan dan nama jelas
LAMPIRAN 8 - 11
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SURAT PERNYATAAN (PENANGGUNG JAWAB TEKNIK )
Yang bertanda tangan di bawah ini :
Nama : ……………………………..……………………………..
Tempat dan tgl lahir : ……………………………..……………………………..
Pendidikan Terakhir : ……………………………..……Jurusan :……………
Nomor Ijazah terakhir : ………………………………........................................
NRKA : ……………………………..……………………………..
Nama Ibu Kandung : ……………………………..……………………………..
adalah benar-benar Penanggung Jawab Teknik dan bekerja penuh waktu pada badan usaha :
Nama : …………………………….……………………………..
Alamat : …………………………….……………………………..
…………………………….……………………………..
Dengan rincian pengalaman kerja sebagaimana terlampir.
Surat pernyataan ini dibuat dengan sebenarnya dan kami sanggup dikenakan sanksi dan dituntut di pengadilan apabila ada keterangan yang diberikan tidak benar.
Demikian pernyataan ini dibuat untuk dipergunakan sebagaimana mestinya............................. 20..
Yang menyatakan
(…………………….) Tanda tangan dan nama jelas
MateraiSesuai ketentuandan capBadan Usaha
LAMPIRAN 8-12. a
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SURAT PERNYATAAN (PENANGGUNG JAWAB TEKNIK )
Surat pernyataan ini dibuat dengan sebenarnya dan kami sanggup dikenakan sanksi dan dituntut di pengadilan
............................ 20..
Yang menyatakan
(…………………….) Tanda tangan dan nama jelas
LAMPIRAN 8-12. a
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SURAT PERNYATAAN (PENANGGUNG JAWAB KLASIFIKASI)
Yang bertanda tangan di bawah ini :
Nama : ……………………………..……………………………..
Tempat dan tgl lahir : ……………………………..……………………………..
Pendidikan Terakhir : ……………………………..……Jurusan :……………
Nomor Ijazah terakhir : ………………………………........................................
NRKA : ……………………………..……………………………..
Nama Ibu Kandung : ……………………………..……………………………..
adalah benar-benar Penanggung Jawab Klasifikasidan bekerja penuh waktu pada badan usaha :
Nama : …………………………….……………………………..
Alamat : …………………………….……………………………..
…………………………….……………………………..
Dengan rincian pengalaman kerja sebagaimana terlampir.
Surat pernyataan ini dibuat dengan sebenarnya dan kami sanggup dikenakan sanksi dan dituntut di pengadilan apabila ada keterangan yang diberikan tidak benar.
Demikian pernyataan ini dibuat untuk dipergunakan sebagaimana mestinya.
Tanda tangan dan nama jelas
MateraiSesuai ketentuandan capBadan Usaha
LAMPIRAN 8-12.b
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SURAT PERNYATAAN (PENANGGUNG JAWAB KLASIFIKASI)
Surat pernyataan ini dibuat dengan sebenarnya dan kami sanggup dikenakan sanksi dan dituntut di pengadilan
............................ 20..
Yang menyatakan
(…………………….) Tanda tangan dan nama jelas
LAMPIRAN 8-12.b
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SURAT PERNYATAAN (TENAGA AHLI TETAP)
Yang bertanda tangan di bawah ini :
Nama : ……………………………..……………………………..
Tempat dan tgl lahir : ……………………………..……………………………..
Pendidikan Terakhir : ……………………………..……Jurusan :……………
Nomor Ijazah terakhir : ………………………………........................................
NRKA : ……………………………..……………………………..
Nama Ibu Kandung : ……………………………..……………………………..
adalah benar-benar Tenaga Ahli Tetap dan bekerja penuh waktu pada badan usaha :
Nama : …………………………….……………………………..
Alamat : …………………………….……………………………..
…………………………….……………………………..
Dengan rincian pengalaman kerja sebagaimana terlampir.
Surat pernyataan ini dibuat dengan sebenarnya dan kami sanggup dikenakan sanksi dan dituntut di pengadilan apabila ada keterangan yang diberikan tidak benar.
Demikian pernyataan ini dibuat untuk dipergunakan sebagaimana mestinya.
Tanda tangan dan nama jelas
MateraiSesuai ketentuandan capBadan Usaha
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SURAT PERNYATAAN (TENAGA AHLI TETAP)
Surat pernyataan ini dibuat dengan sebenarnya dan kami sanggup dikenakan sanksi dan dituntut di pengadilan
............................ 20..
Yang menyatakan
(…………………….) Tanda tangan dan nama jelas
LAMPIRAN 8-12.c
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DAFTAR RIWAYAT HIDUPPENANGGUNG JAWAB TEKNIK DAN PENANGGUNG JAWAB KLASIFIKASI SERTA TENAGA TEKNIK
Nama : …………………………………………………………………
Alamat : …………………………………………………………………
…………………………………………………………………
Agama : …………………………………………………………………
Status : …………………………………………………………………
NRKA : …………………………………………………………………
Tahun lulus : …………………………………………………………………
Nama Ibu Kandung : …………………………………………………………………
Riwayat Pendidikan : ( uraian nama sekolah, lokasi sekolah, tahun lulus )
1. ……………2. ……………dan seterusnya
Kursus-kursus yang diikuti : (sebutkan nama kursus, tempat, lama hari, nomer sertifikat)1. ……………2. ……………dan seterusnya
Pengalaman kerja (tahun s.d tahun, proyek, lokasi, besarnya nilai proyek, nama badan usaha tempat bekerja, jabatan di tempat kerja)1. ……………2. ……………dan seterusnya
Yang membuat,
( ……………………) Tanda tangan dan nama jelas
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DAFTAR RIWAYAT HIDUPPENANGGUNG JAWAB TEKNIK DAN PENANGGUNG JAWAB KLASIFIKASI SERTA TENAGA TEKNIK
Pengalaman kerja (tahun s.d tahun, proyek, lokasi, besarnya nilai proyek, nama badan usaha tempat bekerja, jabatan di tempat kerja)
Yang membuat,
( ……………………) Tanda tangan dan nama jelas
LAMPIRAN 8-13
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IV. DATA PENGALAMAN PEKERJAAN
KLASIFIKASI :SUB KLASIFIKASI : KODE :
Tahun No / Tanggal Waktu Pelaksanaan No Nama Paket Pekerjaan *) Nama Proyek & alamat Kontrak dan NKPK **) Pekerjaan
Lokasi Propinsi Pengguna Jasa / Pemberi Tugas B.A / Tgl Serah Terima Mulai Selesai
1 2 3 4 5 6 7
Catatan : * ) Lampirkan rekaman kontrak dan BA serah terima pekerjaan Direktur Utama / Penanggung Jawab serta PPN proyek tersebut atau SPT Tahunan pada saat proyek dilaksanakan Badan Usaha**) NKPK adalah nomer yang diberikan olek LPJK setelah melaporkan pekerjaannya Bila belum punya harap dikosongkan
***) Untuk perhitungan evaluasi , Nilai Kontrak dapat dikonversi Untuk PMA hanya pengalaman di Indonesia yang ditulis Tanda tangan dan nama jelas Pengalaman yang ditullis cukup yang nilainya besar di sub klasifikasiny dalam 10 tahun terakhir
LAMPIRAN 8-14
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IV. DATA PENGALAMAN PEKERJAAN
Nilai Kontrak ***)Akhir dan Jumlah
Total Kontrak8
Total = Rp
Direktur Utama / Penanggung Jawab Badan Usaha
Tanda tangan dan nama jelas
LAMPIRAN 8-14