Supplier Qualification Statement
SUPPLIER NAME & ADDRESS (Mailing Address and Street Address)
PT. INSTRUMINDO PRIMA SENTOSA
Rukan Crown, Jl. Green Lake City Boulevard No.10, RT.001/RW.010, Petir, Kec. Cipondoh, Kota Tangerang,
Banten 15147
Telephone (021) 5503953 Fax (021) 22588115
Contact 1 081296205258 Title Mulyadi (Sales Engineer)
Contact 2 Title
Primary e-mail address: instrumindo@instrumindo.co.id
Web site address: www.instrumindo.co.id
Duns Number:
I. ORGANIZATIONAL INFORMATION
A. Date Organized 3 September 2008
B. Type of Organization
Corporation
Partnership
Proprietorship
PRINCIPAL POSITION & YEARS WITH
OFFICERS FUNCTION COMPANY
YEARS UNDER PRESENT MANAGEMENT
RELATED PARENT COMPANY, DIVISIONS, & SUBSIDIARIES
C. Number of Permanent Employees:
Office: 22
Shop:
D. Are you certified to International Standards Organization (ISO 9000)? Yes No
If yes, which standard? 9001:2035 Quality Management System Date 25 October 2021
FQ-PUR-001-02 Page 1
Who was certifying organization? International Assessment Certification
E. Do you have a documented Quality Program? Yes No
F. Labor Affiliation
Union Shop* Yes No
Nonunion Shop Yes No
Both Yes No
If Union, National Yes No
Agreements
If yes, which trades
G. Business Size and Classification
Size (Check One)
Small A domestic concern that normally employs less than 500 persons, or as
defined by section 3 of the Small Business Act.
Large A domestic concern which, including domestic and foreign divisions and
affiliates, normally employs 500 or more persons, is independently or publicly
owned or controlled and operated and which may be a division of another
domestic or foreign concern.
Classification (Check where applicable; may be more than one)
Foreign A concern which is not incorporated in the United States or an unincorporated
concern having its principal place of business outside the United States.
Minority A business, at least 50% of which is owned by minority group members, or, in
case of publicly owned businesses, at least 51% of the stock of which is
owned by minority group members. For the purpose of this definition, minority
group members are Black-Americans, Hispanic-Americans, American-
Orientals, American-Indians, American-Eskimos, and American-Aleuts.
Women A business that is at least 51% owned and controlled by a woman or women.
Nonprofit A business or organization that has received nonprofit status under IRS
Regulation 501C3
Sheltered A sheltered workshop or other equivalent business basically employing the
handicapped.
Please indicate in the space below how your firm complies with the above definition.
H. Do you utilize electronic commerce to receive purchase orders and send invoices?
Yes No
If yes, how? EDI Internet Both
FQ-PUR-001-02 Page 2
II. FINANCIAL INFORMATION
A. Are you willing to provide an audited income statement and balance sheet? Yes No
B. Annual Volume (past three (3) years)
Year Revenue Net Worth Current Ratio*
2021 43.104.760.302 260.558.181 35.651.859.843
2020 47.359.803.878 6.466.348.628 39.899.002.428
2019 46.741.990.829 4.871.474 24.082.575.870
*Current Assets/Current Liabilities
C. Dun & Bradstreet Rating:
D. Credit References (Provide 3)
Name Contact Phone Number
E. Major Customers (Provide 3)
Name Contact Phone Number
PERTAMINA EP
PERTAMINA HULU SANGA-
SANGA
PREMIER OIL
III. MANUFACTURING/PRODUCT INFORMATION
A. What are your primary products? (Name top 3 and percentage of sales)
Product Percentage of Sales
DIALIGHT 65%
PARKER 70%
PEPPERL+FUCHS 55%
B. Do you manufacture them or are you a distributor? A DISTRIBUTOR
C. If you are a manufacturer:
(1) What design codes are you qualified to manufacture to?
(2) Where are your manufacturing plants located? (City, State/Country)
City State/Country
FQ-PUR-001-02 Page 3
D. If you are a distributor:
(1) Where are your distribution points?
City State/Country
BEKASI JAWA BARAT/INDONESIA
(2) What manufacturers do you represent?
Manufacturer
E. Safety Record
Year:
Your firm’s interstate experience modification rate (EMR)
From your OSHA No. 200 log:
A. Number of lost workday cases
B. Number of restricted workday cases
C. Number of cases with medical attention only
D. Number of fatalities
OSHA Lost Workday Rate (See 1 below)
OSHA Recordable Case Rate (See 2 below)
1. OSHA Lost Workday Rate should be calculated for each year using the following formula:
(A + D above) x 200,000
Employee Hours Worked (Given Year)
2. OSHA Recordable Case Rate should be calculated for each year using the following formula:
(A + B + C + D above) x 200,000
Employee Hours Worked (Given Year)
Do you have in place a Controlled Substance Testing Procedure? Yes No
F. Have you had any OSHA fines within the last 5 years?* Yes No
G. Have you had any environmental violations within the last 5 years?* Yes No
FQ-PUR-001-02 Page 4
*If the answer to either F or G is yes, please provide details.
Date: 28/02/2023 Submitted by: Henny Gosal
Phone Number: (021) 5503953
E-mail address: instrumindo@instrumindo.co.id
mulyadi@instrumindo.co.id
FQ-PUR-001-02 Page 5
