dokumen kualifikasi pengawasan
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7/26/2019 dokumen kualifikasi pengawasan
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STANDAR DOKUMEN KUALIFIKASIPENGADAAN JASA KONSULTANSI
(BADAN USAHA)
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D O K UM E N K U AL I F I K A S I
Nomor : ………………………………………………
Tanggal : ! D"#"m$"r %&
'n'
P"nga*aan
P""r+aan Pengawasan Pembangunan Jalan Poros Desa Kawasan SP
Distrik Mimika Kabupaten Mimika
P"+a$a P"m$'a Kom,m"n : PENGEMBANGAN KAWASAN PERMUKMAN
PERDESAAN
Sam,nal : !P"A KAR#A
K"m"n"r,an P""r+aan Um'm
Ta-'n Anggaran: %&%
K E M E N T E R I A N P E K E R J A A N U M U M
DIREKTORAT JENDERAL CIPTA KARYASATKER PENGEMBANGAN PERMUKIMAN DAN PERBATASAN PAPUAPELAKSANAAN KEGIATAN PENGEMBANGAN KAWASAN PERMUKIMAN PERDESAANAlamat : Jln. Sumatera Nmr. !" D# I$ Tel%. &'()*+ ""'!,' - a/. &'()*+ ""'!,' Ja0a%ura
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DAFTAR ISI
BABI UMUM .................................................................................... 1
BABII PENGUMUMAN PRAKUALIFIKASI ....................................... 3
BAB III INSTRUKSI KEPADA PESERTA (IKP) .................................. 4
BABIV LEMBAR DATA KUALIFIKASI(LDK) .................................... 15
BAB V SURAT PERJANJIAN KEMITRAAN ..................................... 17
BAB VI PAKTA INTEGRITAS…………………………………………… 19
BAB VII FORMULIR ISIAN KUALIFIKASI …………............................ 22
BAB VIII PETUNJUK PENGISIAN FORMULIR ISIAN
KUALIFIKASI ........................................................................ 2
BABI! TATA "ARA EVALUASI KUALIFIKASI ................................ 31
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BAB. I UMUM
A. D#$%&' K%*+,+$-+ ++ +-%-% /'0-0$ P'0%0 P0'-+' R'%/*+$I#'-+ N#� 54 T% 21 ' P' B06J- P'&'0+.
B. D*& D#$%&' K%*+,+$-+ ++ +'0%$ ''0+ +-+* -+$-'/+ /'0+$%8
/ Ja#a Kon#'lan#, 8 - *: 0#,'-+#* :&'&/%%$ $'*+ '0'% +/'0/+/+ $'+*&% : &'%&$: #* +$'0 (brainware);
< Harga P"r,raan S"n*,r, (HPS) 8 -+* '0+% -'*%0% =#*%&''$'0 +$*+$ ' >0 S%+&/ ' -'*%0% /'/ $ $'%%;
/ K"m,raan 8 $'0 -& %- 0 ':'+ :&-+<&-+ +$ &'&%:+ $$'?+/ % ?/ : '*-/'0-0$ '0+ '0%*+-;
/ LDK 8 L'&/0 D K%*+,+$-+;/ Pan,,a P"nga*aan 8 K'*#&#$ K'0 : /'0,%-+ %%$
&'*$-$ '&+*+ ':'+/06- *& P'B06J-.
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D. P' &'**%+ 0$%*+,+$-+ ++ +/+:+ 0+ -%&/'0 ' :'0%& *& LDK.
E. P++ P' &'%&%&$ '*$- 0$%*+,+$-+ &'**%+ *&website ???.%.#.+ '%&%& 0'-&+ %%$ &-:0$ P#0*P' N-+#* &'**%+ LPSE.
F. P0$%*+,+$-+ ++ '0/%$ ++$%+ #*' -'&% '-'0 : /'0/'%$/ %-.
BAB II PENGUMUMAN PRAKUALIFIKASI
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PENGUMUMAN PRAKUALIFIKASI
N#� 8 &012gm/2ra1on#l1,m/2a2'a12.&01%&
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L+$% '$'0 8 P"nga3a#an P"m$ang'nan Jalan Poro#.
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+uta
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K E M E N T E R I A N P E K E R J A A N U M U M
DIREKTORAT JENDERAL CIPTA KARYA
SATKER PENGEMBANGAN PERMUKIMAN DAN PERBATASAN PAPUAPELAKSANAAN KEGIATAN PENGEMBANGAN KAWASAN PERMUKIMAN PERDESAANAlamat : Jln. Sumatera Nmr. !" D# I$ Tel%. &'()*+ ""'!,' - a/. &'()*+ ""'!,' Ja0a%ura
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BAB III. INSTRUKSI KEPADA PESERTA IKP
A. UMUM. Pan,,a
P"nga*aan *anL,ng'2P""r+aan
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P' 0 *+ &'*+%+8. %/% $'*%0 $0''0$?+ $'%0% -&+' '0 $'% /+$ -'0#0+#* &%% ='0+$*;
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B. DOKUMEN KUALIFIKASI
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D#$%&' K%*+,+$-+ /'-'0 -'*%0%$#0'-#'-+ '0%*+- *& 0#-'-$%*+,+$-+ &'%$ B-I#'-+.
;. P"r'$a-an S'/'*%& /- $+0 ?$%
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&. B"rla'n4aK'al,6,a#,
K%*+,+$-+ ++ : /'0*$% %%$$' '$'0 : '0%& *&LDK.
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11.1 P'-'0 -''%: &'%/+: %%$ &'+$%+ $%*+,+$-+ ++.
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%. P"ng,#,anDo'm"nK'al,6,a#,
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5. B"n'Do'm"n
D#$%&' K%*+,+$-+ +-&+$-'/:$ 3 (+) 0$ : '0+0+
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14.2 P'-'0 &':&+$ *-%D#$%&' K%*+,+$-+ $' P++P' -'-%+ ?* :+'$ *& LDK.
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?* : +'$ *& LDK.
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0. P"r#4araan P'0-:0 K%*+,+$-+ *
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17.3 D< *& ,#0&%*+0 +-+$%*+,+$-+ +*'$+ -&+' /- $+0 '&-%$#$%&' $%*+,+$-+.
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6% '%0%-: +&-%$$*& D,0 >+&.
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>-+* $%*+,+$-+ -''* +'$ #*'P++ P' +/'0+%$$' -'*%0% '-'0 +%&%&$ #*' P++ P'&'**%+ *& ???.%.#.+ '%&%& 0'-&+ %%$&-:0$.
%. Sangga-an 21.1 P'-'0 &':&+$
- '0%*+- $' P++P' *& ?$% 5 (*+&) 0+$'0 -''* '%&%& -+*$%*+,+$-+ +-'0+ /%$+ '0+:':+& ' '&/%-$' PPK PA6KPA I-'$#0J''0* K'&''0+ PU -'-%+ :'0%& *& LDK.
21.2 S +%$ #*' '-'0 /+$-'0 -'+0+<-'+0+ &%%/'0-&<-& ' '-'0 *+/+* '0+ ':+& 0#-'%0 &'*+%+8. ':+& '0 $''%
0#-'%0 : +%0 *&P'0% P0'-+' ++ :'* +'$ *& D#$%&'K%*+,+$-+;
/. 0'$:- '0'% -'+&'*+ '0+: '0-+%- : -'; 6%
. ':*% ?'?' #*'P++ P' 6%'/ : /'0?' *+:.
21.3 P++ P' ?+/ &'&/'0+$ ?/ '0%*+- - -'&%- -'*&/*&/: 5(*+&) 0+ $'0 -''* &''0+&
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-%0 -.
21.4 A/+* - +:$ /'0 &$ P++ P' &':$-'*'$-+ *.
21.5 T+$ - /+ *&0#-'- 0$%*+,+$-+.
%%. K'al,6,a#,Ulang
22.1 A/+* %&* '-'0 : *%*%-$%*+,+$-+ $%0 0+ 5 (*+&) %%$S'*'$-+ U&%& % $%0 0+ 3 (+)%%$ S'*'$-+ S''0 &$+*$%$ '%&%& %*0$%*+,+$-+ %%$ &'0+ '-'0/0% -'*+ '-'0 : '* *%*%-
'+*+ $%*+,+$-+. P'-'0 :-% *%*%- '+*+ $%*+,+$-+ +$'0*% +*$%$ '+*+ $'&/*+$'%*+ '0%/ D#$%&'K%*+,+$-+.
22.2 J+$ -''* $%*+,+$-+ %* '0:'-'0 : *%*%- $%*+,+$-+ /'0%&*$%0 0+ 5 (*+&) %%$ S'*'$-+U&%& % $%0 0+ 3 (+) %%$S'*'$-+ S''0 &$ 0#-'-
-'*'$-+ +*%$.
%5. Un*angan"2a*aP"#"raK'al,6,a#,4ang L'l'#
J+$ +$ - %- +#*$ &$ '-'0 :&-%$ *& D,0 P''$ +%%%$ &'&/+* D#$%&' P'&+*+%%$ &'&-%$$ '?0.
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BAB I>. LEMBAR DATA KUALIFIKASI (LDK)
A. Pan,,aP"nga*aan *anL,ng'2P""r+aan
1. N& P++ P' 8 Satker Pengembangan
Kawasan Permukiman
-an Perbatasan Papua A*& P++ P' 8 Jl$ Sumatera No$ %.
Dok$ / Ja0apura A*& C'/-+' 8 www$pu$go$i-
2. N& P$' P'$'0 8 Pengawasan
Pembangunan Jalan
Poros Desa Kawasan
SP Distrik Mimika
Kabupaten Mimika
3. L+$% P'$'0 8 Pengawasan
Pembangunan JalanPoros Kawasan SP
Distrik Mimika Kab$
Mimika
B. S'm$"r Dana P' ++ +/+:+ 0+ -%&/'0 '8 APBN
T% A0 212
<. B"rla'n4aK'al,6,a#,
K%*+,+$-+ ++ : /'0*$% %%$ $' '$'0
Pengawasan Pembangunan Jalan Poros Desa Kawasan
SP Distrik Mimika Kabupaten Mimika
D. P"n4am2a,anDo'm"nK'al,6,a#,
>0+ 8 S'*-T* 8 27 D'-'&/'0 211P%$%* 8 9. C+. -.. 15. C+.T'& 8 J*. S%&'0 N#. 15 D#$. IV J:%0.
E. P"r#4araanK'al,6,a#,
1. P'-'0 $%*+,+$-+ : /'0/ %- 0%- &'&+*+$+
-%0 ++ %- J- I-'$-+.
2. &'&+*+$+ ,-+*+- 6 '0* 6 '0-#+* %%$ &'*$-$'$'0 - $#-%*-+ ++ :+%8 K#&%'0 P0+'0 A3
"&'0 D++* GPS.
F. P"r#4araanT"n,#K'al,6,a#,
1. &'&+*+$+ '*& '$'0 J- I-'$-+
' #* /#/# '+*+ -'/'-0 @ .
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2. &'&+*+$+ T' A*+ T' ' $%*+,+$-+ $'*+
B+ S++* A0-+'$%0 L+$% '
'*& &++&* 1 (-%) % ' #* /#/#
'+*+ -'/'-0 4 ;
3. A/+* +'0-:0$ '$'0 $#&*'$- &$ 0%-
&'&+*+$+ -'0+,+$ &'&' &%% ISO % '0-:0
*+ -''0+ '0* $%-%- ' *+ -'-+*+- :
+'0*%$ % '*& '0'% %%$ '$'0
$#&*'$- ' /#/# : /'-0: &'%0+
/#/# '*& '0%- -'/'-0
G. Sangga- T'&/%- - +-&+$ $'8
1. PPK . P''&/ K?- P'0&%$+&
P'0'- P%
2. KPA . S$'0 P''&/ K?- P'0&%$+&
P'0/- P%
3. -.
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BAB >. SURAT PERJANJIAN KEMITRAAN
BENTUK SURAT PERJANJIAN KEMITRAAN 1 KERJA SAMA OPERASI (KSO)
SURAT PERJANJIAN KEMITRAAN 1
KERJA SAMA OPERASI (KSO)
MENIMBANG :
BA1WA(
S'%/% ' -'*'$-+ '$'0 ..................... : '&/%$ '?0:
$ +*$%$ + .................. * .......... 2...... &$ 8
.................................. [nama peserta 1],
.................................. [nama peserta 2],
..................................[nama peserta 3],
...................................[dan seterusna]!
/'0&$-% %%$ &'+$%+ '*'* '*$- $#0$ -'0 /'0-&<-&
*& /'%$ $'&+06K'0 S& O'0-+ (KSO).
MEN?ETUJUI DAN MEMUTUSKAN :
BA1WA(
1. S'0 /'0-&<-&8
1. M'&/'%$ $'&+06KSO ' & $'&+06KSO * ............2. M'%%$ ................... [nama peserta 1] -'/+ '0%- %& "leading #irm$
%%$ $'&+06KSO &'?$+*+ -'0 /'0+$ %%$ - &
$'&+06KSO.
3. M':'%%+ /+* +%%$ -'/+ '&' ?+/ /'0% ?/ /+$
-'0 /'0-&<-& % &-+<&-+ - -'&% $'?+/ -'-%+
$''% #$%&' $#0$.
2. K'+$%-'0 "sharing$ -'+ '0%- *& $'&+06KSO *8
P'-'0 1 ............ (....................'0-') 0+ &#* 6% ' *+
P'-'0 2 ............ (....................'0-') 0+ &#* 6% ' *+P'-'0 3 ............ (....................'0-') 0+ &#* 6% ' *+
................ -''0%-:.
3. M-+<&-+ '-'0 # $'&+06KSO $ &'&/+* /+ -'-%+
sharing '0-'/% /%+0 2. *& * ''*%0 $'%% $'0%+ 0+
$'&+06KSO. P'&/+ sharing *& $'&+06KSO ++ +$ $ +%/ /+$
"ONTO>
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-'*& &- '?0 &%% -' &- $#0$ $'%*+ '
'0-'%% '0%*+- '0*'/+ %*% 0+ P++ ' % P'/ P'&/%
K#&+&' (PPK) '0-'%% /'0-& -'0 '0%*+- 0+ &-+&-+
# $'&+06KSO. T'0*'- 0+ sharing : +'$ +- &-+<
&-+ # $'&+06KSO $ &'*$%$ '?- '% '0
-'&% -'$ '*$- 0+ '0+ ++ '0&-%$ $ %%$ &'&'0+$-$'% '0+ '&/'*+ '0+& ,0 '0* ' $'0
'0+ -%/$#0$ -%0<&':%0 '*'$- *+<*+.
4. C'?' &'+ %%$ - & $'&+06KSO +/'0+$
$' ................... [nama wakil peserta ang diberi kuasa] *& $'%%$:
-'/+ '&+&+6+0'$%0 %& '0%- ..................[nama peserta 1]
/'0-0$ '0-'%% '0%*+-) 0+ .............[nama peserta 2] .......................
[nama peserta 3] .....................[dan seterusna] -'%/% ' -%/--+
-'&% $''% *& -'&% #$%&' : $ + +.
5. P'0+ ++ $ /'0*$% -'$ * ++.
@. P'0+ ++ -'0 ##&+- &'+ /* +$ /'0*$% *+ /+* -'*'$-+ +$
+&'$ #*' '0%- $'&+06KSO.
7. P'0+ ++ +/% *& 0$ .............. (....................) : &-+<&-+
&'&%:+ $'$% %$%& : -&.
DENGAN KESEPAKATAN INI -'&% # $'&+06KSO &'&/%/%$
+ .............. 0+ ............... * ........... /%* ............. % ......................
P':'+ 1 P':'+ 2 P':'+ 3
(.............................) (............................) (............................)
-''0%-:
(...............................)
D+-$ #*' NOTARIS)
(...............................)
) sebelum menandatangani dokumen%dokumen atas nama kemitraan harus
mendapatkan persetu&uan tertulis dari anggota kemitraan'KS(!
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) dapat disahkan setelah kemitraan ditun&uk sebagai pelaksana peker&aan dengan
ketentuan prosentase kemitraan dan perusahaan ang mewakili kemitraan tersebut
tidak berubah!
BAB >I. PAKTA INTEGRITAS
[)ontoh Pakta *ntegritas +adan saha -anpa Kemitraan]
PAKTA INTEGRITAS
S: : /'0 + /? ++8
N& 8 .................... [nama wakil sah badan usaha]
J/ 8 ....................
B'0+$ %%$ 8 PT6"V6F+0&6K#'0-+6K'&+0.................... - & 8 …………………………………[ pilih ang sesuai dan .antumkan
nama ]
*& 0$ ' .................... .................... [isi sesuai dengan
Satuan Ker&a di lingkungan Kementerian P] ' ++ &':$ /?8
1. +$ $ &'*$%$ 0$'$ K#0%-+ K#*%-+ N'#+-&' (KKN);
2. $ &'*#0$ $' +$ : /'0?+/6/'0?' /+* &''%+
++$-+ KKN *& 0#-'- ' ++;
3. $ &'+$%+ 0#-'- ' -'0 /'0-+ 0-0 0#,'-+#*
%%$ &'&/'0+$ -+* $'0 '0/+$ -'-%+ $''% '0%0 '0%<
%;
4. /+* &'*0 *<* : +:$ *& PAKTA INTEGRITAS ++
/'0-'+ &''0+& -$-+ &++-0+, &''0+& -$-+ '%& *&
D,0 >+& +% -'0 '0 6% +*#0$ -'0 +.
.................... [tempat] ............[tanggal] .................... [bulan] 2... [tahun]
[/ama Penedia]
[tanda tangan]
[nama lengkap]
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[)ontoh Pakta *ntegritas +adan saha Dengan Kemitraan]
PAKTA INTEGRITAS
K&+ : /'0 + /? ++8
1. N& 8 .................... [nama wakil sah badan usaha]
J/ 8 ....................
B'0+$ %%$ 8 PT6"V6F+0&6K#'0-+6K'&+0.....................................
- & 8 ..................................... [pilih ang sesuai dan .antumkan
nama]
2. N& 8 .................... [nama wakil sah badan usaha]
J/ 8 ....................
B'0+$ %%$ 8 PT6"V6F+0&6K#'0-+6K'&+0.....................................
- & 8 ..................................... [pilih ang sesuai dan .antumkan
nama]
3. ......[dan seterusna, diisi sesuai dengan ¨ah anggota kemitraan]
*& 0$ ' .................... .................... [isi sesuai dengan
Satuan Ker&a di lingkungan Kementerian P] ' ++ &':$ /?8
1. +$ $ &'*$%$ 0$'$ K#0%-+ K#*%-+ N'#+-&' (KKN);
2. $ &'*#0$ $' +$ : /'0?+/6/'0?' /+* &''%+
++$-+ KKN *& 0#-'- ' ++;
3. $ &'+$%+ 0#-'- ' -'0 /'0-+ 0-0 0#,'-+#*
%%$ &'&/'0+$ -+* $'0 '0/+$ -'-%+ $''% '0%0 '0%<%;
4. /+* &'*0 *<* : +:$ *& PAKTA INTEGRITAS ++
/'0-'+ &''0+& -$-+ &++-0+, &''0+& -$-+ '%& *&
D,0 >+& +% -'0 '0 6% +*#0$ -'0 +.
.................... [tempat] ............[tanggal] .................... [bulan] 2... [tahun]
[/ama Penedia]
[tanda tangan]
[nama lengkap]
[/ama Penedia]
[tanda tangan]
[nama lengkap]
[/ama Penedia]
[tanda tangan]
[nama lengkap]
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BAB >II. FORMULIR ISIAN KUALIFIKASI
S: : /'0 + /? ++8
N& 8 .................... [nama wakil sah badan usaha]
J/ 8 ....................
B'0+$ %%$ 8 PT6"V6F+0&6K#'0-+6K'&+0.....................................
- & 8 ..................................... [pilih ang sesuai dan .antumkan
nama]
A*& 8 ...................................
T'*'#6FH 8 .....................................
E&+* 8 ......................................
&':$ ' -'-%%: /?8
1. -: -'0 %$%& &'&%:+ $-+- &'+ $#0$
/'0-0$ S%0 .................... [sesuai akte pendirian'perubahanna'surat
kuasa, disebutkan se.ara &elas nomor dan tanggal akte pendirian'perubahan'surat kuasa! Jika Kemitraan maka Surat dimaksud
adalah Per&an&ian Kemitraan!] ;
2. -: /%$ -'/+ '?+ K6L6D6I [bagi pegawai K'0'D'* ang sedang .uti
diluar tanggungan K'0'D'* ditulis sebagai berikut Saa merupakan pegawai
K'0'D'* ang sedang .uti diluar tanggungan K'0'D'*] ;
3. -: +$ -' &'*+ -$-+ +;
4. -: +$ -' +$ $ '0*+/ '0' $''+ '
0 +$ : '0$+ *-% &%% +$ *-% *& 0#-'-
' ++;
5. / %- : -: ?$+*+ +$ &-%$ *& D,0 >+& +$ *&
'?- '+* +$ +*+ $'+ %-: +$ -'
+'+$;
@. -* -% 6% -'&% '%0%- / %- : -: ?$+*+ +$
&-%$ *& D,0 >+&
7. < -:6/ %- : -: ?$+*+ * -'/+ /'0+$%8
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A. Daa A*m,n,#ra#,
1.N& (PT6"V6F+0&6K#'0-+6K'&+0) 8
………………………………………
2. S%-8
P%- "/
K'&+0
3.
A*& 8 …………………………………..N#.T'* 8 …………………………………..N#. FH 8 ………………………………….E&+*
8……………………………………
4.
A*&8
…………………………………..N#.T'* 8 …………………………………..N#. FH 8 ……………………………………E&+*
8……………………………………
B. I@,n U#a-a
1. S%0 I+ U- ............ 8 N#. ………………. T* ……………
2. M- /'0*$% ++ %- 8 …………………………
3. I--+ '&/'0+ ++%-
8 …………………………
<. I@,n La,nn4a (a2a$,la *,2"r#4araan)
1. S%0 I+ U- ............ 8 N#. ………………. T* ……………
2. M- /'0*$% ++ %- 8 …………………………
3. I--+ '&/'0+ ++%-
8 …………………………
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D. Lan*a#an H''m P"n*,r,an Ba*an U#a-a1K"m,raan
1. A$' P'+0+ PT6"V6F+0&6K#'0-+6K'&+0
. N#. A$' 8 ………………………../. T* 8 ………………………... N& N#0+- 8 ………………………..
2. A$' P'0%/ T'0$+0
. N#. A$' 8 …………………………
/. T* 8 …………………………. N& N#0+- 8 …………………………
E. P"ng'r'#
. Kom,#ar,# 'n' P"r#"roan T"r$aa# (PT)
No. Nama No. KTPJa$aan *alam Ba*an
U#a-a
%. D,r"#,1P"ng'r'# Ba*an U#a-a1K"m,raan
No. Nama No. KTPJa$aan *alam Ba*an
U#a-a
5. Kom,#ar,# Ba*an U#a-a
No. Nama No. KTPJa$aan *alam Ba*an
U#a-a
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F. Daa K"'angan
. S'#'nan K"2"m,l,an Sa-am ('n' PT)1S'#'nan P"#"ro ('n'<>1F,rma)1S'#'nan K"m,raan
No. Nama No. KTP Alama Pr"#"na#"
%. Pa+a
. N#� P#$#$ C+/ P$ 8 ……………………/. B%$+ L#0 P$ T%
'0$+0
8 N#. ………………………..T* …………………..
. B%$+ L#0 /%* (+
/%* '0$+0)
8
1) PP P-* 21 8 N#. ………………………..T* …………………..
2) PP P-* 23 (/+*
0-$-+)
8 N#. ………………………..T* …………………..
3) PP P-* 256P-* 29 8 N#. ………………………..
T* …………………..4) PPN 8 N#. ………………………..
T* …………………..
G. Daa P"r#onal,a (T"naga a-l, "a2 $a*an '#a-a1"m,raan)
No. NamaTgl1$ln1T-n
La-,r T,nga
P"n*,*,an
Ja$aan*alam
2""r+aan
P"ngalamanK"r+a (a-'n)
Pro6"#,1K"a-l,an
Ta-'nS"r,6,a1I+a@a-
% 5 7 ! 0 9
H. Daa P"ngalaman P"r'#a-aan & (#"2'l'-) a-'n "ra-,r
No.NamaPa"
P""r+aan
B,*ang1S'$
B,*angP""r+aan
Loa#,
P"m$"r,T'ga#1P"+a$a
P"m$'a Kom,m"nKonra
Tanggal S"l"#a,M"n'r'
NamaAlama1T"l"2on
No 1Tanggal
N,la, KonraBA
S"ra-T"r,ma
1 2 3 4 5 @ 7 9 1
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I. Daa P""r+aan 4ang #"*ang *,la#anaan
No.NamaPa"
P""r+aan
B,*ang1S'$B,*ang
P""r+aan
Loa#,
P"m$"r,T'ga#1P"+a$a
P"m$'aKom,m"n
Konra
Tanggal S"l"#a,
M"n'r'
NamaAlama1T"l"2on
No 1Tanggal
N,la,Konra
(r"nana)
Pr"#a#,K"r+a ()
1 2 3 4 5 @ 7 9 1
J. Daa Fa#,l,a#1P"ralaan1P"rl"nga2an 4ang m"n*''ng[.antumkan &ika disaratkan oleh Panitia Pengadaan]
N#.J'+-
F-+*+-6P'0*6P'0*'$
J%&*
K-+-%
output -
++
M'0$+'
T%'&/%
K#+-+()
L#$-+S'$0
B%$+K''&+*+$)
1 2 3 4 5 @ 7 9
) B%$+</%$+ -%0 $''&+*+$ 0%- +%%$$ ?$% +'0*%$
D'&+$+ '0: ++ -: /% ' -'/'0: '% 0- %
?/. J+$ +$'&%+ 0+ +'&%+ /? 6#$%&' : -: -&+$
+$ /'0 % '&*-% &$ -: / %- : -: ?$+*+
/'0-'+ +$'$ -$-+ /'0% -$-+ &++-0+, -$-+ '%&
*& D,0 >+& % -'0 '0 6% '*#0 -'0 +
$' +$ /'0?' -'-%+ ' $''% '0%<%.
.................... [tempat] ....... [tanggal]
................ [bulan] 2 ..... [tahun]
PT6"V6F+0&6K#'0-+6K'&+0
.................... [pilih ang sesuai dan
.antumkan nama]
[rekatkan meterai p 4!555,% dan tanda
tangan]
(nama lengkap wakil sah badan
usaha'kemitraan)
[&abatan pada badan usaha'kemitraan
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BAB >III. PETUNJUK PENGISIAN FORMULIR ISIANKUALIFIKASI
A. A*m,n,#ra#,2. D++-+ ' & / %- '-'06$'&+0.
3. P+*+ -%- / %- (P%-6"/6K'&+0). U%$ : /%$
P%-6"/6K'&+0 0 &'+-+ -%- P%-.
4. D++-+ ' *& #� '*'# #� ,$-+&+*+ e%mail /
%- '-'06$'&+0 : +%/%+.
5. D++-+ ' *& #� '*'# #� ,$-+&+*+ e%mail $#0
%- : +%/%+ : ++-+ /+* '-'0 /'0-%- $#0
/.
B. I@,n U#a-a
A0 -'/'*%& &'+-+ +-+$ ++ %- +&$-% * : +&+*+$+
#*' / %- : &'+$%+ $%*+,+$-+.
1. D++-+ ' '+- -%0 ++ %- #� * ''0/+:.
2. D++-+ ' &- /'0*$% ++ %-.
3. D++-+ ' & +--+ ''0/+ -%0 ++ %-.
<. I@,n la,nn4a (a2a$,la *,2"r#4araan)
A0 -'/'*%& &'+-+ +-+$ ++ *+: +&$-% * : +&+*+$+
#*' / %- : &'+$%+ $%*+,+$-+.1. D++-+ ' '+- -%0 ++ #� * ''0/+:.
2. D++-+ ' &- /'0*$% ++.
3. D++-+ ' & +--+ ''0/+ -%0 ++.
D. Lan*a#an H''m P"n*,r,an Ba*an U#a-a1K"m,raan
1. D++-+ ' #� * & N#0+- ''0/+ $' '+0+
/ %-6$'&+0.
2. D++-+ ' #� * & N#0+- ''0/+ $' '0%/
'0$+0 / %-6$'&+0 /+* .
E. P"ng'r'#
1. D++-+ ' & #� KTP / *& / %- /+*
/'0/'%$ P'0-'0# T'0/-.
2. D++-+ ' & #� KTP / *& / %-6$'&+0.
3. D++-+ ' & #� KTP / *& / %-.
F. Daa K"'angan
1. D++-+ ' & #� KTP *& '&+*+$ -&6'-'0#6#
$'&+0 '0-'-' $''&+*+$ -&6'-'0#6$'&+0.
2. P$
. D++-+ NPCP / %-.
/. D++-+ #� * /%$+ L#0 P$ T% '0$+0 /'0% SPT
T%.
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