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FORMULIR PENILAIAN KUALIFIKASI PEKERJAAN
JASA KONSULTANSI
PENGADAAN JASA KONSULTAN
PEKERJAAN : JASA KONSULTAN PERENCANAAN GEDUNGPERKANTORAN SKPD (15 UNIT)
LOKASI : NIAS BARAT
SUMBER DANA : REVISI DPA – P.APBD DINAS PEKERJAAN UMUMKABUPATEN NIAS BARAT TA. 2012
TAHUN ANGGARAN : 2012
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DAFTAR FORMULIR ISIAN PRAKUALIFIKASI
NO URAIAN
1. SURAT PENGANTAR DOKUMEN PRAKUALIFIKASI
2. FAKTA INTEGRITAS
. FORMULIR ISIAN PENILAIAN KUALIFIKASI
!. A. DATA ADMINISTRASI
1. UMUM
B. IJIN USAHA JASA KONSTRUKSI
C. LANDASAN HUKUM PENDIRIAN PERUSAHAAN
D. PENGURUS PERUSAHAAN
E. DATA KEUANGAN
1. SUSUNAN KEPEMILIKAN SAHAM
2. PAJAK
F. DATA PESONALIA
DATA PENGALAMAN PERUSAHAAN
DATA PEKERJAAN YANG SEDANG DIKERJAKAN
LAMPIRAN :
1. AKTE PENDIRIAN PERUSAHAAN
2. REKAMAN KTP PENGURUS PERUSAHAAN
3. SERTIFIKAT BADAN USAHA
4. REKAMAN IJIN USAHA JASA KONSTRUKSI
5. REKAMAN DATA PERPAJAKAN
6. DATA PENDUKUNG TENAGA AHLI
7. REKAMAN BUKTI PENGALAMAN PEKERJAAN
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SURAT PENGANTAR DOKUMEN PRAKUALIFIKASI
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STRUKTUR ORGANISASIPT. SANTO PUTRA ANUGRAH
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Ir. TPS.
R U P S Komisaris
Direktur Utama
Direktur I
Santo DPS
Divisi Arsitektur
Ir. Yanuar M, IAI
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Ir. Togap PS
Divisi Jasa Survey
Ir. Morlan T.
Divisi Jasa
Management
Ir. Joan !S,MT
Divisi Tata
"ingkungan
Ir. Tunggul S.
Kepala Divisi
Sekretaris
Asisten Tenaga
Ali
Juru #am$ar !%%i&e Manager Pelaksana
A'ministrasi
Dan !(
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F A K T A I N T E G R I T A S
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SURAT PERN3ATAAN MINAT
UNTUK MENGIKUTI PENGADAAN PAKET PEKERJAAN JASA KONSULTANPERENCANAAN GEDUNG PERKANTORAN SKPD (15 UNIT)
PADA PANITIA PELELANGAN UMUM4 PENUNJUKAN LANGSUNG DANPENGADAAN LANGSUNG JASA KONSULTANSI PERENCANAAN DAN
PENGAASAN KEGIATAN TAHUN JAMAK TAHUN 2012 – 2015 PADA DINASPEKERJAAN UMUM KABUPATEN NIAS BARAT
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SURAT PERN3ATAANB(9( B((+ U$(( Y(+ B!$(+-(+ D(+ M(+(++>( T*( D((
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S U R A T P E R N 3 A T A A N
SALAH SATU DAN%ATAU SEMUA PENGURUS BADAN USAHA TIDAK MASUK DALAMDAFTAR HITAM PERUSAHAAN
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S U R A T P E R N 3 A T A A N
MEMPEROLEH PALING SEDIKIT 1 ,SATU/ PEKERJAAN SEBAGAI PENYEDIA JASAKONSULTANSI DALAM KURUN AKTU 4 ,EMPAT/ TAHUN TERAKHIR; BAIK DI
LINGKUNGAN PEMERINTAH MAUPUN SASTA TERMASUK PENGALAMANSUBKONTRAK
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S U R A T P E R N 3 A T A A N
MEMILIKI KEMAMPUAN PADA SUB BIDANG PEKERJAAN 3ANG SESUAI67
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S U R A T P E R N 3 A T A A N
MEMILIKI KEMAMPUAN MENYEDIAKAN FASILITAS DAN PERALATAN SERTAPERSONIL YANG DIPERLUKAN UNTUK PELAKSANAAN PEKERJAAN
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S U R A T P E R N 3 A T A A N
KEBENARAN DATA
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FORMULIR ISIAN PENILAIAN KUALIFIKASI
PENGADAAN JASA KONSULTANSI JASA KONSULTAN PERENCANAANGEDUNG PERKANTORAN SKPD (15 UNIT)
PADA PANITIA PELELANGAN UMUM4 PENUNJUKAN LANGSUNG DANPENGADAAN LANGSUNG JASA KONSULTANSI PERENCANAAN DAN
PENGAASAN KEGIATAN TAHUN JAMAK TAHUN 2012 – 2015 PADA DINASPEKERJAAN UMUM KABUPATEN NIAS BARAT
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F. PENGURUS PERUSAHAAN
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N%. N"'" N%. KTP J"","$ D"#"'
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G. DATA KEUANGAN
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1. P""
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PERHITUNGAN RUGI LABA
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