PT Kustodian Sentral Efek Indonesia - Post Trade Processing Lamp6pendncd

(1)

FM-ECA-20-2003 (1/2), Rev.0

Nomor Faksimili

Fax Number

:

7.

Surat Elektronik

Email Address

:

9.

Pejabat Berwenang 1 1s t_{Authorized Contact}

8.

No. NPWP

Tax Number

:

Pejabat Berwenang 2 2nd Authorized Contact

B. Data NCD

4.

Tanggal Listing (dd/mm/yy)

Issue Date

:

5.

Tanggal Jatuh Tempo (dd/mm/yy)

Maturity Date

:

6.

Nilai NCD Yang Dikeluarkan

Amount Issued

:

Terbilang

Say

:

7.

Tingkat Suku Bunga

Current Interest Rate

:

%

8.

Periode Pembayaran

Payment Period

:

1.

Surat Perjanjian KSEI – Emiten KSEI – Issuer Agreement

_6.

Surat kuasa penunjukkan 2 pejabat berwenang dilampiri dengan fotokopi kartu identitas Power of Attorney to authorized 2 persons attached with copies of ID cards

2.

Fotokopi NPWP Copy of Tax Number

_7.

Specimen tandatangan & paraf pejabat ber wenang Specimen of Signature & initial of official

3.

Fotokopi Akta Pendirian/Anggaran Dasar Copy of Established Deed/Article of Association

_8.

Contoh cap perusahaan Emiten Issuer stamp sample

4.

Surat Keterangan Domisili Letter of Domicile

_9.

Spesimen sertifikat

Specimen of securities sertificates

5.

Surat pernyataan efektif dari BAPEPAM Copy of registration statement

(2)

FM-ECA-20-2003 (2/2), Rev.0

D. Pengesahan /

Validation

Dengan menandatangani Formulir Pendaftaran NCD ini, kami menyatakan tel ah membaca dan memahami seluruh peraturan KSEI tentang penitipan kolektif di KSEI serta setuju untuk tunduk dan mematuhi peraturan tersebut.

By signing this NCD Registration Form, we declare that we have read and understood all KSEI regulation regarding the collective custody in KSEI, as well as we are subject to and abide by those KSEI regulation.

Kami menyatakan bahwa semua keterangan dan dokumen yang kami berikan kepada KSEI adalah lengkap dan benar. We declare that all information and documents submitted to KSEI are correct and complete.

Jakarta _____/_____/_____ Petugas KSEI*)

KSEI Officer

(………..) (………..) (……….)

Nama & Tanda Tangan Pejabat berwenang 1

Name & Signature of 1s t_{Authorized Signature} _{Name & Signature of 2}Nama & Tanda Tangan Pejabat berwenang 2 nd_{Authorized Signature} Nama, Tanda Tangan dan Cap _{Name, Signature and Stamp}

E. Status

*)

1. Pemeriksaan Dokumen oleh Bagian Hukum Chec ked by Legal Department

2. Input Data Inputted by

3. Persetujuan Approved by

(……….) (……….) (……….)

Nama & Tanda Tangan Name & Signature

Nama & Tanda Tangan Name & Signature *Hanya diisi oleh Petugas KSEI