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Form for Registration of Counterparties (Know Your Customer/KYC)

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Form for Registration of Counterparties (Know Your Customer/KYC) ATTACHMENT 2 Form for Registration of Counterparties (Know Your Customer/KYC) 1. Corporate Details In keeping with the standard industry practice it is important that you provide us with the following background information. Full registered company name Any trading name(s): Incorporation date Country of Incorporation Corporate status (Listed, Pvt. Ltd., Partnership, firm etc) If listed, please name Stock Exchange(s) and Name of the Chairman/ listing(s) President/ Managing Director Registered street address Post code Tax ID Physical address of head office Company registration number Town / City Telephone number Website Parent/ Holding company, if any (and its main business) Subsidiary (ies), if any (and its main business) Department/ Initial point of contact Mobile number for Pertamina at the Company: Fax number E-Mail address Please provide copies of the below documents. These documents should be provided in the English Language or with an English Translation. 2. Company Identification Details All document required in this KYC should be provided in hardcopy and compact disc (CD). Mandatory documents to be provided Mandatory documents to be Please Tick (X) Reference No. Please Tick (X) provided 2.1 Certificate of Incorporation or Memorandum/ Articles 2.5 List of Shareholder and capital share of Association and Amendments 2.2 Register of Commerce issued by Government 2.6 List of Authorized signatories with signatures (ACRA / Approved Oil Trader (AOT) / Global Trader authentication Program (GTP) / business register / Surat Ijin Usaha Perusahaan (SIUP) & Tanda Daftar Perusahaan (TDP) or other related documents) 2.3 List Of Company Committee (Commissioners & 2.7 Copy of ID Card or Passport for authorized Directors) signatories (2.5) 2.4 Certificate of Residence / Domicile (For Indonesia Company only) Note: Documents above (2.1 and 2.2 ) shall be legalized by your Ministry of Foreign Affairs or your Ministry of Justice and legalized by Local Indonesia Embassy. 3. Financial Highlights Mandatory Documents to be Provided Please Tick (X) 3.1 Please attach audited Annual Reports for each of the last 3 years. 3.2 Two Original Bank References Reference Bank Name 1: Reference Bank Name 2: 3.3 In Addition, please provide summary of the financial data, in the following format FINANCIAL DATA (in USD) 2016 2017 2018 Cash & Bank Short Term Marketable Securities Total Trade Receivables Current Assets Construction in Progress / Asset Under Construction Depreciation & Amortization Total Asset Current Liabilities Total Liabilities Total Equity Total Operating Revenue Total Revenue EBIT EAT ATTACHMENT 2 Form for Registration of Counterparties (Know Your Customer/KYC) 4 Banking Details Please provide the full banking details 4.1 Principal Bankers (Name of the Bank) 4.2 Swift BIC 4.3 Bank Branch Address Details 4.4 Bank City & Country 4.5 Bank Account Name (Beneficary Name) 4.6 Currency of Bank Account 4.7 Bank Account Number/ IBAN number 4.8 Name of Bank Account Manager & Contact Details 5. Business Details 5.1 Does your Company have more than 3 years of business activity specifically in Oil Trading? In case the response to 3.1 is "No", please elaborate 5.2 Is your Company currently (or has been in the last 3 Independent Oil Please Trading years) registered with any of the following companies National Oil Company Please Tick (x) Please Tick (x) Company Tick (x) Company and/or any of their subsidiaries BP ADNOC Glencore Chevron Corporation ENI Koch ConocoPhillips / Phillips Indian Oil Corporation Mercuria 66 Exxon Mobil NNPC Noble Group Royal Dutch Shell Saudi Aramco Trafigura Total Sinopec Vitol Petronas Petredec Socar Gunvor Others Others (detail) (detail) 5.3 Please Provide Physical Trade volume for Crude & Volume of Physical Purchase Transactions in MT Products for Past Three years in the following table *Inter company/group transactions may kindly be excluded* split by Purchase & Sell transactions. 2016 2017 2018 Crude Gasoline Diesel Fuel oil LPG Jet fuel / Avgas Volume of Physical Sell Transactions in MT *Inter company/group transactions may kindly be excluded* 2016 2017 2018 Crude Gasoline Diesel Fuel oil LPG Jet fuel / Avgas 5.4 Does your Company or any of its affliated Subsidiary own and/or operate an Oil Refinery? In case the response to 3.4 is "Yes", please provide Operate Refinery Name Capacity (kbpd) Ownership (%) details per below (Y / N) ATTACHMENT 2 Form for Registration of Counterparties (Know Your Customer/KYC) ATTACHMENT 2 Form for Registration of Counterparties (Know Your Customer/KYC) 5.5 Does your company own vessels that can be used to supply In case the response to 3.5 is "Yes", please provide Number of Age of Vessel Vessel type details per below Vessel < 10 Years 10 - 20 Years > 20 Years ULCC / VLCC VLGC Suezmax Aframax Others 5.6 Does your company own / rent storage facilities in the region that may be used to supply In case the response to 3.6 is "Yes", please provide Capacity Type Own / Rent details as per below (cubic meters) Crude Product LPG 6 Other Details 6.1 Does your company and your committee currently under dispute(s) with Pertamina and it's affiliate? In case the response to 6.1 is "Yes", please elaborate 6.2 Any other relevant information 7 Declaration 7.1 It is hereby declared that the information and particulars furnished above are true and correct to the best of my/our knowledge and belief and that nothing has been misrepresented and/or concealed 7.2 If later found that the information above are not true and there is forgery, Pertamina has a right to impose an administrative sanction, to claim compensation, a civil lawsuit, canceling a Letter of Award (LOA) and terminate a contract or has a right to impose any sanction according to Pertamina regulation. 8 Signature Name of authorized person completing this Date: Registration Form * Position Location: *) If Registration Form is filled by unauthorized person, please provide the Power of Attorney Letter (Legalized by Indonesia Embassy).
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