FORMULIR KEANGGOTAAN BMPPVI* Nama Perusahaan :.......................................................................................................... .................. Kedudukan Hukum :............................................................................................................................. .............................................................................................................................. .............................................................................................................................. Akta Pendirian No............................................. tanggal : .......................... Notaris ....................... Pengesahan Badan Hukum No............................... tanggal :............................................................... Ijin Operasional OJK No ..........................................tanggal :.............................................................. Nomor NPWP No:........................................................................................................................ Keanggotan APPI No :........................................... Tanggal :............................................................. Susunan Direksi :

1. ................................................................................................................................................. 2. ................................................................................................................................................. 3. ............................................................................................................................................... 4. ................................................................................................................................................

Susunan Komisaris :

1. ............................................................................................................................................... 2. ............................................................................................................................................... 3. ................................................................................................................................................ 4. ................................................................................................................................................

Daftar Pemegang Saham :

1. ............................................................................................................................................... 2. .............................................................................................................................................. 3. ..............................................................................................................................................

Jenis Usaha Pembiayaan :

1. .............................................................................................................................................. 2. ............................................................................................................................. ............... 3. ............................................................................................................................................

Total Aset :.................................................(...................................................................................) Jumlah kantor cabang/Perwakilan :................................................................................................. Petugas Perusahaan yang ditunjuk dalam pengurusan Keanggotaan BMPPI.......................................... ......................,..................20... PT............................................. Nama :............................................... Jabatan :.............................................

*mohon formulir dapat dilengkapi dengan fotokopi dokumen-dokumen sebagai berikut: 1. Akta Pendirian 2. Anggaran Dasar sampai dengan perubahan terakhir 3. Akta Susunan Direksi Komisaris terakhir 4. NPWP 5. SIUP (Ijin OJK) 6. Domisili 7. Company Profile 8. Laporan Keuangan (audited) terakhir seluruhnya disampaikan pada kantor sekretariat di alamat sebagai berikut: Badan Mediasi Pembiayaan Pegadaian dan Ventura Indonesia Kantor Sekretariat: Gedung Yarnati Lantai 2 Ruang 206 Jalan Proklamasi No.44 Menteng, Jakarta Pusat up. Rahmawati