Pre qualification document (pasar seni link) new

MASS RAPID TRANSIT CORPORATION SDN BHD(Company No. 902884-V)

(A Company Fully Owned by Minister of Finance Incorporated)

PROJEK MASS RAPID TRANSIT LEMBAH KELANG:JAJARAN SUNGAI BULOH – KAJANG (SBK)

PRE-QUALIFICATION DOCUMENT

FOR

PROPOSED CONSTRUCTION AND COMPLETION OF PASAR SENI PAID LINK AND OTHER ASSOCIATED WORKS

BETWEEN EXISTING PASAR SENI LRT STATION AND KUALA LUMPUR KTM STATION

PRE-QUALIFICATION NO.: MRTCORP/KVMRT-SBK/CW/35/105-2015

JULY 2015

PROJECT DELIVERY PARTNER (PDP)

MMC GAMUDA KVMRT (PDP) SDN BHD (Company No. 927050-H)

PROJEK MASS RAPID TRANSIT LEMBAH KELANG: Pre-Qualification Document JAJARAN SUNGAI BULOH – KAJANG (SBK)Pasar Seni Paid Link Package

APPENDIX 1

Form A LETTER OF APPLICATION

Form B COMPANY PROFILE

Form C FINANCIAL DATA

Form D LIST OF PAST PROJECTS EXPERIENCE RECORD

Form E LIST OF CURRENT PROJECTS

Form F LIST OF SIMILAR PAST PROJECTS (LAST 10 YEARS)

Form G COMPANY ORGANISATION CHART

Form H EXISTING KEY PERSONNEL IN THE ORGANISATION

Form I EXISTING KEY PERSONNEL C.V

Form J PLANT / EQUIPMENT – OWNED OR LEASED

Form K QUALITY, SAFETY, HEALTH AND ENVIRONMENTAL PLAN

Form L LITIGATION (CURRENT & LAST 10 YEARS)

Form M REPORT BY PROJECT ARCHITECT / ENGINEER ON CONTRACTOR’S PERFORMANCE ON CURRENT PROJECTS

Form N REPORT BY PROJECT ARCHITECT / ENGINEER ON CONTRACTOR’S PERFORMANCE ON COMPLETED PROJECTS

Form O PARENT COMPANY GUARANTEE

Form P APPLICANT’S LETTER OF RECOGNITION

Form Q DETAILS OF CONTRACTUAL RELATIONSHIP BETWEEN MEMBERS OF JOINT VENTURE OR CONSORTIUM

MRTCORP/KVMRT-SBK/CW/35/105-2015


FORM A - LETTER OF APPLICATION

JV Company Non – JV Company

(Please tick () accordingly)

[Letterhead of the Company/ Consortium/ JV including full postal address, telephone no., fax no. and email address]

Date: September 17, 2015

Mass Rapid Transit Corporation Sdn Bhd Level 5, Menara I & P1 No. 46 Jalan DungunBukit Damansara50490 Kuala Lumpur Malaysia

Dear Sirs,

Pre-Qualification Application for the Proposed Construction and Completion of Pasar Seni Paid Link and Other Associated Works between Existing Pasar Seni LRT Station and Kuala Lumpur KTM station for Projek Mass Rapid Transit Lembah Kelang: Jajaran Sungai Buloh – Kajang

1.0 We PT. Wijaya Karya (persero) Tbk have read the Pre-Qualification Document and understand the instructions and requirements and hereby apply to be prequalified as a Tenderer for the above Works Contract Packages.

2.0 We understand that MRT Corp/PDP may at its sole discretion prequalify or disqualify our application without giving any reasons for its decision.

3.0 We authorize MRT Corp/PDP or its authorized representatives to conduct any investigations to verify the statements, documents and information submitted and to clarify the financial and technical aspects of this application. For this purpose, we hereby authorize any public official, engineer, bank, depository, manufacturer, distributor, etc. or any person or firm to furnish pertinent information deemed necessary and as requested by MRT Corp/PDP to verify statements and information provided in this application regarding our competence and standing.



The names and designations of the authorized persons from our company to be contacted for queries and/or provide additional information:

General and Management InquiriesName: Ir. Siddik Siregar

Designation: General Manager of Overseas Department, PT. Wijaya Karya (persero) Tbk

Tel: +62(021)8192808,8508640 , 8508650

E-mail: [email protected]

Technical InquiriesName:

Designation:

Tel:

E-mail:

Commercial and Financial InquiriesName: Agung Riris Ermantoro, ST

Designation: Commercial Manager of Overseas Department, PT. Wijaya Karya (persero) Tbk

Tel:+62(021)8192808,8508640 ,850865 0

E-mail: [email protected]

4.0 We declare that the statements made and the information provided in this application are complete, true and correct in every detail and aspect.

Applicant’s Signature …………………………………………

Name in Full …………………………………...(Authorized Representative) Designation ……………………………………

Date ………………………………………….

Signature …………………………………………

In the presence of ………………………………………..(Name in full) (Witness)

Designation ………………………………………..

Address ……………………………………….

Date ……………………………………….Note : Please submit a Power of Attorney or Certified Extract of Board of Director’s

Resolution authorizing the above to sign on behalf of the Company.


tel:+62(021)8192808,8508640

tel:+62(021)8192808,8508640

tel:+62(021)8192808,8508640


FORM B - COMPANY PROFILE



Company's Name: PT. Wijaya Karya (persero) Tbk

1. Registered Office Address

Facsimile +62(021)8564463, 8191235, 8199678

No. Email Address [email protected] No. +62(021)8192808,8508640 ,

8508650

2. Correspondence Address

Facsimile +62 21 8191235, 8199713No. Email Address [email protected]

Telephone No. +62(021)8192808,8508640 , 8508650

3. Date of Incorporation December 20, 1972Authorized Capital 173,066,717.24 (RM)

Paid-Up Capital Enclosed in our attachment

Shareholders’ fund Enclosed in our attachment

Shareholders Company Share Holding Equity (List up to 10 major shareholders only)

Name of Shareholders Percentage Equity

1.Government 65.15%2.Domestic Individual 4.78%3.WIKA's Employee 1.60%4.Cooperative 0.08%5.institution 0.43%6.Pension Fund 2.52%7.Insurance 2.17%8.Bank 0.98%9.Company 7.83%10.Reksadana 0.03%


tel:+62(021)8192808,8508640

tel:+62(021)8192808,8508640


11.Foreign Individual 0.03%12.Foreign Coorporate 14.42%TOTAL 100.0%

Directors: Names, qualification and experience of members of Board of Directors

Name of Director Academic & Professional

Qualifications

Age Years of Working Experience

1.Bintang Perbowo, SE, MM -Master Degree in International Management from the Prasetya Mulya Business School in 2007

-Bachelor Degree in Economics from the University Krisnadwipayama, Jakarta in 1990.

61 y.o

He has been reappointed as President Director since May 25, 2013 and re-elected as Director since April 22, 2015. Previously, he served as President Director in 2008-2013 periods. He is the Financial Director of PT Pembangunan Perumahan (Persero) in 1999-2008 periods and has other important positions in the company

2.Yusmar Anggadinata -Master Degree in Management of Technology from Bandung Institute of Technology in 1997

-Bachelor Degree in Physics from Bandung Institute of Technology in 1990.

52 y.o

Previously, he was Business Development Director of PT Angkasa Pura II (2014-2015), Senior Economist of Logistics for Asian Development Bank (2013-2014), Economic Affairs Officer in the field of Port Development for the United Nations Economic and Social Commission for Asia and the Pacific (2012), and Consultant for the World Bank in the field of Transport and Logistics of Trade (2012-2013)

3. Ir. Gandira Gutawa, MM - Master Degree in Management from the University of Indonesia in 2000

-Bachelor Degree in Civil Engineering from Bandung Institute of Technology (1985).

53 y.o

He has been a Director of PT Wijaya Karya (Persero) Tbk. since April 22, 2015. Previously, he served important positions in the Civil Works Department. He was the Project Manager of Bekri Irrigation Project in Lampung in 2004 as well, until he was appointed as Manager of the General Civil Department I in 2007, and he finally appointed to be the General Manager of the department.



Ir. Destiawan Soewardjono, MM -Bachelor Degree in Civil Engineering from University of Brawijaya, Malang in 1987

-Master Degree in Management from University of Gadjah Mada, Yogyakarta in 2008

54 y.o

He has become the Director of Operation III of PT Wijaya Karya (Persero) Tbk. since May 25, 2013. Destiawan Soewardjono started his career in PT Wijaya Karya (Persero) Tbk. since 1988 and other operational positions in WIKA as the General Manager of Overseas Division (2012-2013), Manager of Overseas Division (2008-2011), and Project Manager of East West Motorway – Aljazair (2009-2010)

3. Ir. Budi Harto, MM -Master of Management Degree University of Gajah Mada, Yogyakarta in 1997

-Bachelor Degree in Civil Engineering University of Sebelas Maret, Surakarta in 1983.

56 y.o

He has been appointed as Deputy Managing Director since April 22, 2015. Previously, he as Director of Operational I since April 25, 2013 to April 22, 2015. In addition, he is the President Commissioner of PT WIKA Gedung since 2013 and previously as Director of Operations I (2008-2013 ) WIKA Gedung. He began his career in the Company since 1984 and has held several important positions, among others: President Commissioner of PT WIKA Gedung (2009-2010), President Commissioner of PT WIKA Intrade (2008-2009), General Manager of the General Civil in 2008, and General Manager Operation 1 (2006-2007) .

5. Drs. Adji Firmantoro, MM -Master Degree from PPM Business School, Jakarta (1997)

-Bachelor Degree in Economics from University of Gadjah Mada, Yogyakarta

58 y.o

He became the Director of Finance in PT Wijaya Karya (Persero) Tbk. since April 25th, 2013, and as the President Commissioner of PT WIKA Industri & Konstruksi since 2013. Adji Firmantoro started his



(1984) career in PT WIKA Beton since 1984 and had been assigned in several important positions in the Subsidiary Companies, among others: Director of Finance of PT WIKA Beton (2002-2011) and PT WIKA Intrade (2011-2013)

6. Ir. Bambang Pramujo, MT - Masters & Bachelor Degree in Civil Engineering from the University of Indonesia.

58 y.o

Currently he is the Director of Operations of PT Wijaya Karya (Persero) Tbk since May 25, 2013. In addition, he is the President Commissioner of PT Wika Rekayasa Konstruksi since 2013. Bambang Pramujo began his career in PT Wijaya Karya (Persero) Tbk. since 1984 and has held several important positions in the Company and its subsidiaries, including: Commissioner of PT Wika InsanPertiwi (July-October 2013) and President Commissioner of PT Marga Nujyasumo Agung (MNA). He was also General Manager of several business units, for example EPC Dept., Dept. Energy, Utilities Dept., and Industrial Plant Dept. (2005-2013)

4. Particulars of registration with the Construction Industry Development Board Malaysia (CIDB) PPK Grade G7 and SPKK

a) Date of Registration :.……………………

b) Registration No :…………………….

c) Validity of Registration :…………………….

d) Grade :…………………….

e) Category :…………………….

Note : Please submit certified true copy of valid CIDB PPK Grade G7 and SPKK certificates.




Name in Full ………………………………….(Authorized Representative) Designation ……………………………………Date …………………………………………..



FORM C - FINANCIAL DATA




1. Summary of assets and liabilities as shown in the audited balance sheets for the last 5 financial years.

Item

Description Actual : Last 5 Financial Years (RM)

2010 2011 2012 2013 20141 Authorized

Capital168,910,214.33 169,634,287.27 171,839,688.44 172,806,183.83 173,066,717.24

2 Paid-up Capital

20,1474,707.17 200,880,170.03 212,789,004.20 180,513,736.10 169,517,511.06

3 Total Assets 1,769,247,592.95 2,357,121,523.48 3,101,737,494.65 3,544,786,291.41 4,479,238,906.83

4 Current Assets

1,394,358,158.99 1,655,935,156.06 2,040,653,110.03 2,174,115,699.63 2,587,535,739.99

5 Total Liabilities

1,229,783,293.33 1,731,884,799.85 2,304,038,925.01 2,636,575,615.80 3,077,993,478.71

6 Current Liabilities

1,025,029,362.61 1,456,361,402.80 1,851,998,687.17 2,385,537,763.40 2,054,116,007.32

7 Net Worth 539,464,299.62 625,236,723.64 1,401,245,428.12 908,210,675.61 1,401,245,428.12

8 Shareholder’s Funds

50,839,548.73 52,890,535.22 55,788,332.72 57,029,658.92 58,229,511.42

9 Working Capital

369,328,796.37 199,573,753.25 188,654,422.86 195,834,666.98 292,253,388.17

10 Annual Turnover

1,695,119,824.70 2,178,896,741.33 2,787,770,711.41 3,344,877,441.86 3,507,706,936.83

Notes: All the original financial report is served in Indonesian Rupiah (IDR) , and they are converted into Malaysian Ringgit (MYR). 1 MYR = 2,931 IDR (2010), 1 MYR = 2,894.95 (2011), 1 MYR = 3,142.39 (2012), 1 MYR =3,687.44 (2013), 1 MYR = 3,542.64 (2014) ( Resource http://www.bi.go.id/id/moneter/informasi-kurs/transaksi-bi/)



Name and address of the Bank where the Account is opened

1. a. Bank Mandiri : Jl. Jenderal Gatot Subroto Kav. 36-38. Jakarta 12190 Indonesia

b.Account Number : 006 - 0098056231 (IDR) 006 - 0098056553 (USD)

006 - 0005570704 (IDR)

2. a. Bank Rakyat Indonesia (BRI) : Kantor Pusat Gedung BRI 1 Jl. Jenderal Sudirman Kav.46 Bendungan Hilir, Tanah Abang, Jakarta 10210, Indonesia

b.Account Number : 206 - 01- 002445 - 30 - 9 (IDR) 206 - 02 - 000557- 30 – 0 (USD)

3. a. Bank Negara Indonesia (BNI) : Wisma 46 Kota BNI 42 Floor, JL. Jend Sudirman Kav 1, Jakarta, 10220, Indonesia

b. Account Number : 0124063017 (IDR) 0124065718 (USD)

4. a. Bank of HSBC : World Trade Center Kav, 29 - 31 Lantai G/M/3/4, Jl. Jend Sudirman, Kec. Setiabudi, Kota Jkt Sel., Daerah Khusus Ibukota Jakarta 12920, Indonesia

b. Account Number : 050 - 155837 - 068 (IDR) 050 - 155837 - 115 (USD) 050 - 155837 - 116 (JPY)

2. Credit Facilities

a. Name and address of the Bank / Financial Institution providing credit facilities

Form and Balance of the amount which can be used for the construction.

Amount Committed(RM)

Balance(RM)

(i) Overdraft Or Annual Credit 661,412,877.05 292,871,379.88(ii) Secured Overdraft - -

(iii) Fixed Loan 329,579,234.04 163,131,040.15(iv) Others - -

TOTAL (RM) 990,992,111.09 456,002,420.03

Notes: All the original financial report was served in Indonesian Rupiah (IDR) , and they have been converted into Malaysian Ringgit (MYR). 1 MYR = 2,931 IDR (2010), 1 MYR = 2,894.95 (2011), 1 MYR = 3,142.39 (2012), 1 MYR =3,687.44 (2013), 1 MYR = 3,542.64 (2014) ( Resource http://www.bi.go.id/id/moneter/informasi-kurs/transaksi-bi/)



Notes :

All financial figures quoted must be in Ringgit Malaysia (RM).

Applicants must submit the certified true copy audited Company Account/Annual Report by Certified Accountant for the last five (5) years to support the data submitted. Application submitted without the certified true copy audited account shall be disqualified.

Applicants must submit the certified true copy of the Monthly Bank Statement for the last three (3) months before the closing date of the pre-qualification including certificate /latest statement for unpledged deposits and other unpledged short term investment.

Applicants are to insert the letter of confirmation from bank on their banking facilities.

All attachments shall be certified true copy by the Company Secretary or a Grade A officer from a Government body. Failing which the Applicant’s submission will not be considered.

3. Approximate value of balance of work in hand as at 30 June 2015.

All Figures in Ringgit Malaysia (RM)

Name of Project

Contract Value

(RM)

% Completion as at 30 June

2015

Balance to be Completed

Schedule of Works to be Completed

% RM % RM1. Mass Rapid Transit package CP 101

2. Mass Rapid Transit package CP 102


286,678,585.71

253,217,808.07

244,385,689.90

272,093,094.54

4%

4%

18.24%

18.24%

275,211,442.28

243,089,095.75

199,809,740.06

222,463,314.09

April 13, 2018

April 13, 2018

May 20, 2018

May 20, 2018




Total Value of Balance of Work 940,573,592.18

Note: Please attach certified copy of the latest interim payment certificate for each project and certified copy of Letter of Award / Contract.

Applicant’s Signature …………………………………………Name in Full …………………………………. (Authorized Representative) Designation …………………………………..Date …………………………………………



FORM D – LIST OF PAST PROJECTS EXPERIENCE RECORD




(List of all completed projects for the last 10 years)

No

Project Title & Type of Contract (eg:

Conventional, D&B, Turnkey etc)

Project Owner

Brief description of structural steel

component such as value, total quantity in

tonnage, etc

Registration Agency

(CIDB)/Class Incl. Heads

& Sub-heads

Contract Sum (RM) Contract Period

Date Commencement

Date for Completion

Name, Address and Telephone

No .of S.O/Consult

ant

Name, Address and Telephone No. of Project Owner/ Client

Original Final Contract Actual

1USAID Bridge/ Road Reconstruction and Rehabilitation In Aceh

US Agency for International development

The Reconstruction of 32 Km New Roads including Bridges, with the Structural Concrete K 450, K 300, Structural Steel, Precast Structural Post, and Concrete Hollow Core Planks

282,000,386.15 282,000,386.15 18 months September 4, 2008

18 months

February 4, 2010

Parsons-USAID, Banda Aceh

Komplek Dolog Tanjong, Jl. Tanjung Indah Utama No. 1 Desa Tanjong, Banda Aceh 23371, Aceh, Telp: (0651) 8011166, Fax: (0651) 8011167

2

Program of Activity Road Construction of Sorek-Teluk Meranti-Guntung Road Construction

Riau Provience Goverment,Settlement and Infrastrucuture Region Department

The construction are 187,6 km of road. Earthworks contain cut and fill, land clearing for strengthening the soil. Concrete working and piling. Installing elastomer pad, Drainage work and finishing works

54,134,547.00 54,134,547.00 51 months December 15, 2004

51 months

March 31, 2010

Riau Goverment, Region Department

Goverment Provience Riau, Jl. Riau No. 1 Telp. (0761) 22608-22774, Pekanbaru



3East-West Motorway Project, Eastern Package, Algeria

(Consortium Japonais Pour L'Autoroute Algerienne) 15 , Rue Des Freses Benali KAJIMA COJAAL Abdellah Hydra, Alger

The project is construct The freeway of East-West Motorway in Tadjenanet in which constitute until the border of Kingdom Morocco. The works contain Earth Work, Drainage Works, Operation of Batching Plants and Truck Mixer, Line marking, Kerb stone and Guardrail Installation, Prepatory Works for Asphalt Works 104 KM and production of precast.

158,100,000,00 158,100,000,00 26 months July 16, 2007

26 months

August 01, 2010 COJAAL

COJAAL, Rue Des Freses Benali Kajima

4

Jakarta Outer Ring road Section W1 Kebon Jeruk -Penjaringan Package 4 and Package 5 Toll Road Construction

PT. Jakarta Lingkar barat Satu

Construction of Jakarta Outer Ring Toll Road Section W1 Kebon Jeruk-Penjaringan. The project contain earth works like cut and fill existing land, land clearing, soil strengthning, Pavement works, drainage works and external works.

120,314,937.85 120,314,937.85 23 months October 4, 2007

23 months

September 2, 2009

PT. Jakarta Lingkar barat Satu

PT Jakarta Lingkar Barat satu,Jalan Gatot Subroto 54 Jakarta 10260

5Construction of Jakarta Outer Ring Road Section E-3 (CakunG-Cilincing)

PT Jasa Marga (Persero) Tbk

The toll road project link Cakung-Cilincing section E3, Including bridge with I Girder. Construction carried out is traffic management required.

87,682,163.6 87,682,163.6 28 months July 14, 2004

28 months

November 15,2006

PT Jasa Marga (Persero) Tbk

Jasa marga, Toll Plaza Taman Mini Indonesia Indah, Jakarta Timur 13550

6 Casablanca Flyover Minsitry of Public Works

The prooject required number of pile dia.1.5 m=237 pcs, with box girder. The total lenght of the project is 1.150 m. Method of construction using balance Cantilever System

84,655,891.50 84,655,891.50 25 months November 22, 2010

25 months

December 18, 2013

Minsitry of Public Works

Departemen Pekerjaan Umum, Jl. Taman Jati Baru No.1 Jakarta 10150



7Achmad Yani Flyover Project, Summarecon Bekasi

PT Summarecon Agung Tbk

This project have lenght of 38 km. The required project is girder, main bridge with girder, and concrete Fc 50 Mpa. The Method construction used balance cantilever system.

50,669,429.39 50,669,429.39 22 months March 16, 2011

22 months

February 23, 2013

PT Summarecon Agung Tbk

Summarecon, Jl. Perintis kemerdekaan No. 42 Jakarta 13210

Note: a) Please attached certificate(s) of completion, letter(s) of award and contract(s) for the projects listed above.


Name in Full ………………………………………..(Authorized Representative) Designation ………………………………………..

Date ……………………………………….



FORM E – LIST OF CURRENT PROJECTS




No Project Title & Type of Contract (eg: Conventional, D&B, Turnkey etc)

Project Owner

Brief description of

structural steel component

such as value, total quantity in

tonnage, etc

Registration Agency (CIDB)/Class Incl. Heads

& Sub-heads

Contract Sum (RM million)

Contract Period

Date of Commence

ment

Current Progress

%


No. of S.O/Consultant

Name, Address and Telephone No. of Project Owner/

Client

1.

2.

Note: a) Please attached certified interim progress payment certificate(s), letter(s) of award and contract(s) for the projects listed above.



Date ……………………………………….



FORM F – LIST OF SIMILAR PAST PROJECTS (LAST 10 YEARS)



(List of similar completed projects for the last 10 years). Only similar works shall be listed.

No

Project Title & Type of Contract (eg: Conventional, D&B, Turnkey etc)

Project Owner

Brief description of structural steel

component such as value, total quantity in

tonnage, etc

Registration Agency

(CIDB)/Class Incl. Heads & Sub-

heads

Contract Sum (RM million)

Contract Period

Date of Commenc

ement

Date for Completion


No. of S.O/Consultant


No. of Project Owner/ Client

Original Final Contract Actual

1

Construction of Railway Double Tracking of Kroya - Yogyakarta on Java South Line, Phase I (Kutoarjo-Yogyakarta)

The Republic of Indonesia Ministry of Communications Directorate General of Land Communications

Scope of this construction are general works, civil works, building works, track works, substation system, OH. Contract system, Power distribution system, signalling system, telecommunication works, and mechanical works

175590771459 (idr) 36

monthsApril 24, 2004

36 months

March 30, 2007

Jabotabek Railway Project

Jabotabek Railway Project, Jl. Ir Juanda Jakarta Pusat

Note: a) Please attached certificate(s) of completion, letter(s) of award and contract(s) for the projects listed above.

Applicant’s Signature …………………………………………MRTCORP/KVMRT-SBK/CW/35/105-2015



Date ……………………………………….



FORM G – COMPANY ORGANISATION CHART


(Please tick () accordingly)Company's Name: PT. Wijaya Karya (persero) Tbk(Company organization chart comprising existing key personnel and with defined lines of instructions/reporting as well as the authority/ responsibility.)



Date ………………………………………



FORM H – EXISTING KEY PERSONNEL IN THE ORGANISATION




Names of Employees who will be available for the proposed Works Packages and their current positions in the company

No Name Age Education / Professional Qualification

Graduation Year Year of Experience (Design / Construction / Maintenance)

1.

2.

3.

4.

5.

Slamet Adi Susilo

Sartono Amin Nugroho

Ali Afandi

Aminuddin Hidayat

Bibin Awabin

44

54

43

45

39

Civil Engineering

Civil Engineering

Civil Engineering

Civil Engineering

Civil Engineering

1996

1996

1995

2000

2002

22 Years

21 Years

17 Years

20 Years

19 Years



6.

7.

8.

9

11

Felix Manaek Parluhutan, ST

M. Yusrizal

Untung Tri Uripto

Yusril Amri

Siddik Widiarto Pramono

39

51

44

42

51

Civil Engineering

Civil Engineering

Civil Engineering

Civil Engineering

Civil Engineering

2000

2005

2003

2003

1990

10 Years

13 Years

12 Years

14 Years

21 Years

Note: Please attach:(i) Certified copies of the certificates of qualification and memberships of professional bodies.(ii) Curriculum Vitae / Resume of key personnel as provided in Form I.(iii) Company’s latest monthly staff EPF contribution statement shall be provided.

(Certified true copy by the Company Secretary or a Grade A officer from a Government body).



Date ……………………………………….



FORM I – EXISTING KEY PERSONNEL C.V


(Please tick () accordingly)Name of Applicant

Slamet Adi Susilo

Job Title

Project Manager

Personnel information

Name :

Slamet Adi Susilo

Date of birth :

July 14th 1961

Academic qualifications:

Civil Engineering

Professional qualifications:

Project Manager

Present employment

Name of employer: PT. Wijaya Karya (persero) Tbk

Address of employer: Jl. D.I. Panjaitan Kav. 9, Jakarta – 13340

Telephone: 021 – 8192808, 8508640/50 Contact (Name of Reporting Manager)

Achmad Harris

Email: [email protected]

Fax: 021 - 85904146, 8191235 Years with present employer:

22 (Twenty Two ) Years

Job title:

Project Manager

Please summarize professional experience for the number of years specified, in reverse chronological order, indicate particular technical, commercial and managerial experience

relevant to the works, failing which it will not be considered

From to Project Relevant Technical/ Commercial/ Management Experience

Dec 2013 Now Project Manager of Cileunyi-Dawuan-Sumedang Toll Road Project, PT. Wijaya Karya (persero) Tbk

Project Manager

July 2012 Nov 2013 Project Manager of Bogor Outerring Road Construction Project, PT.Wijaya Karya (Persero) Tbk

Project Manager

Aug 2010 June 2012 Project Manager of Surabaya-Mojokerto Highway Project, PT.Wijaya Karya (Persero) Tbk.

Project Manager



Nov 2007 Aug 2009 Project Manager of East West Motorway Algeria Project , PT.Wijaya Karya (Persero) Tbk.

Project Manager

Oct 2005 Oct 2007Project Manager of Road and Bridge PackageBP-07C Pamanukan – Eretan Kulon, West Java, PT.Wijaya Karya (Persero) Tbk.

Project Manager

Dec 2004 Sept 2005Project Manager of Sorek-Teluk Meranti – Guntung Road Development Project Lenght 187, 6 KM - Pekanbaru , PT.Wijaya Karya (Persero) Tbk.

Project Manager

Dec 2002 Nov 2004 Project Manager of Raya Bogor Flyover and Tanjung Barat Flyover, Jakarta , PT.Wijaya Karya (Persero) Tbk.

Project Manager

Mar 1998 Nov 2002 Project Manager Of Jagorawi Toll Road Way Package Cibubur – Cibinong , PT.Wijaya Karya (Persero) Tbk.

Project Manager

May 1997 Feb 1998Engineering Manager of Batam – Tonton Cable Stayed Bridge Project Batam Island , PT.Wijaya Karya (Persero) Tbk.

Engineering Manager

Mar 1996 Apr 1997Commercial Manager of Construction of Road Tanjung Api-Api South Sumatera, PT.Wijaya Karya (Persero) Tbk.

Commercial Manager

Jan 1995 Mar 1996Superintendent of Upgrading of Highway and Bridge IPJP Flyover KS Tuban(, PT. Wijaya Karya (Persero) Tbk.

Superintendent

Jan 1992 Dec 1994Superintendent of Upgrading of Highway and Bridge Arteleri / Kolektor IPJP Flyover Ks-Tuban – Jati Baru- Phase I – V , PT. Wijaya Karya

Superintendent



Name of Applicant


Job Title

Construction Manager


Name :


Date of birth :

June 4th, 1971


Civil Engineering



Present employment




Achmad Harris



21 (Twenty One) Years

Job title:




From To Project Relevant Technical/ Commercial/ Management Experience

Oct 2014 Now Samarinda- Balikpapan Freeway Construction Project, PT. Wijaya Karya (persero) Tbk


Nov 2012 Oct 2014 Cisumdawu Construction Road, PT. Wijaya Karya (persero) Tbk


Dec 2010 Nov 2011 Surabaya - Mojokerto Construction Project, PT.Wijaya Karya (Persero) Tbk


July 2007 Aug 2010 Aceh Road / Bridge Reconstruction and Rehabilitation Project (USAID) , PT.Wijaya Karya (Persero) Tbk.


Nov 2005 July 2007 Construction of causeway Bridge Suramadu Stage II , PT.Wijaya Karya (Persero) Tbk.


Apr 2004 Oct 2005 Cikampek – Padalarang Highway Project, PT.Wijaya Karya (Persero) Tbk.


Augt 2002 Apr 2004 Pancoran Flyover- Jakarta Project, PT.Wijaya Karya (Persero) Tbk.




June 2001 Augt 2002 Jagorawi Toll Road Way Package Cibubur - Cibinong, PT.Wijaya Karya (Persero) Tbk


July 1999 May 2001 Jagorawi Toll Road Way Package Cibubur - Cibinong, PT.Wijaya Karya (Persero) Tbk


Apr 1998 June 1999 Cibubur Interchange Project , PT.Wijaya Karya (Persero) Tbk.

Senior Highway Engineer

July 1997 Apr 1998 Construction of Highway and Bridge Arteri/olektor APBD – Fly Over Penggilingan, Phase I , PT.Wijaya Karya (Persero) Tbk.


Mar 1996 May 1997 Upgrading of Highway and Bridge Arteri/olektor IPJP Fly Over KS Tubun-Jatibaru, Pahase V , PT.Wijaya Karya (Persero) Tbk.

Chief of Engineering

Sep 1995 Feb 1996 DSU Departement , PT.Wijaya Karya (Persero) Tbk. Engineering Staff

Nov 1993 Sep 1994 Seulimeum Irrigation and Dam, PT. Wijaya Karya (persero) Tbk

Project Implementer



Name of Applicant

Ali Afandi

Job Title

Quantity Surveyor


Name :

Ali Afandi

Date of birth :

May 4th 1972


Civil Engineering


Quantity Surveyor

Present employment




Achmad Harris



17 (Seventeen) Years

Job title: Quantity Surveyor




Nov 2014 Now Gempol- Pandaan Toll Construction Project, East Java, PT. Wijaya Karya (persero) Tbk

Quantity Surveyor

Jan 2012 Oct 2014 Cileunyi- Sumedang- Dawuan Construction Road Project, West Java, PT. Wijaya Karya (perasero) Tbk

Quantity Surveyor

Dec 2010 Oct 2011 Toll Balikpapan- Samarinda Project, East Kalimantan, PT. Wijaya Karya (persero) Tbk

Quantity Surveyor

Aug 2009 Dec 2010 Passangger Terminal Construction Of Sultan Syarif Kasim Ii Pekanbaru Airport, PT. Wijaya Karya

Quantity Surveyor

Dec 2007 July 2008 Jakarta Outer Ring Road Construction Project, PT. Wijaya Karya (persero) Tbk

Quantity Surveyor

May 2007 Nov 2007 Surabaya Mojokerto Toll Construction Project. East Java, PT. Wijaya Karya (persero) Tbk

Quantity Surveyor

Mar 2007 Apr 2008 Permanent Homes Project Type 45 Leuhan-West Aceh, PT. Wijaya Karya

Quantity Surveyor



Nov 2005 Feb 2007 Senior Engineer of Operation Bureau at Head Office, PT. Wijaya Karya

Senior Engineer

Aug 2009 Dec 2010 Passangger Terminal Construction Of Sultan Syarif Kasim Ii Pekanbaru Airport, PT. Wijaya Karya

Quantity Surveyor

Apr 2004 Oct 2005 Engineer of Apartement Ciumbeulit Gallery - Bandung, PT. Wijaya Karya

Engineer

Apr 2002 Mar 2004 Engineer or of Gading Mediterania Residences, PT. Wijaya Karya

Engineer

Aug 1999 Mar 2002 Engineerr of Construction of the extension of Taxiway Apron Platform, Including Electrical Facilities and Air Navigation Overlay Existing Platform Sultan Iskandarmuda Aceh airport, PT. Wijaya Karya

Engineer

Aug 1997 Oct 1999 Engineer of Jagorawi Toll Road Way Package Cibubur – Cibinong , PT. Wijaya Karya

Engineer



Name of Applicant

Aminuddin Hidayat

Job Title

Environmental Health and Safety Officer


Name :

Aminuddin Hidayat

Date of birth :

August 28th, 1970


Civil Engineering


Environmental Health and Safety Officer

Present employment




Achmad Harris



20 (Twenty ) years

Job title: Environmental Health and Safety Officer




Oct 2014 Now SHE Officer Samarinda- Balikpapan Freeway Construction Project, PT. Wijaya Karya (persero) Tbk

SHE Officer

March 2011 Sept 2014SHE Officer of of Bogor Outerring Road Construction Project, PT.Wijaya Karya (Persero) Tbk

SHE Officer

Jan 2010 Feb 2011SHE Officer Coordinator Civil general Department, PT Wijaya Karya

SHE Officer

Nov 2008 Dec 2009

SHE Officer of Aceh Road / Bridge Reconstruction and Rehabilitation Project (USAID) , PT.Wijaya Karya (Persero) Tbk

SHE Officer



Jan 2007 Nov 2008

SHE Officer of Aceh Road / Bridge Reconstruction and Rehabilitation Project (USAID) , PT.Wijaya Karya (Persero) Tbk

SHE Officer

May 2005 Jan 2007SHE Officer Suromadu Bentang Tengah Bridge, Surabaya East Java, PT Wijaya Karya

SHE Officer

June 2001 June 2004 SHE Officer Of Gianyar Road, Package IV and Viii, Bali Province

SHE Officer

May 1997 May 2000

SHE Officer Of Northern Coast Road Package Construction Of Cileungsi Fly Over, West Java, PT Wijaya Karya

SHE Officer

Jan1996 Feb 1997

SHE Officer Of Highway and Bridge Arteri / Kolektor IPJP Flyover KS Tubun – Jatibaru, Jakarta, PT Wijaya Karya

SHE Officer

Feb1995 Dec 1996Engineering Staff Hydropower Besai Project, Lampung, PT Wijaya Karya

Engineer Staff

May 1994 Jan1995Engineering Staff Dam Kalola Project, Makasar, PT Wijaya Karya

Engineer Staff



Name of Applicant

Bibin Awabin

Job Title



Name :

Bibin Awabin

Date of birth :

August 7th 1976


Civil Engineering



Present employment




Achmad Harris



19 (Nineteen) YEARS

Job title: Senior Highway Engineer




Dec 2013 Now Samarinda- Balikpapan Freeway Construction Project, PT. Wijaya Karya (persero) Tbk


July 2012 Nov 2013Bogor Outerring Road Construction Project, PT.Wijaya Karya (Persero) Tbk


Oct 2010 June 2012 Road improvement projects on roads and bridges Sicincin Padang Panjang Sumbar, PT Wijaya Karya


Mar 2009 Oct 2010 Bagendang Road Construction Project Sampit Kalteng, PT Wijaya Karya


Aug 2006 Feb 2009 Terminal CAR Development Project Tanjung Priok, PT Wijaya Karya

Asphalt Supervisor

Feb 2004 July 2006 Road contruction Bongkong Nanga Tepuai Nanga Semangut Kalbar




Oct 2002 Jan 2004 Highway construction of Simpang Perdau Batu Ampar II Kaltim


Juni 2001 Oct 2002 Road contruction long bangun Long Boh Long Nawang Kaltim

Asphalt Supervisor

Mar 2000 Juni 2001 Road project kusumba Gianyar Bali, PT Wijaya KaryaSenior Highway

Engineer

May 1998 Mar 2000 Gianyar- Buleleng Road project, PT Wijaya KaryaSenior Highway

Engineer

Oct1996 May 1998 Connecting the dock project koja kanal II, PT Wijaya Karya

Asphalt Supervisor

Jan 1996 Oct 1996 Road and Bridge Barelang project Batam , PT Wijaya Karya

Asphalt Supervisor

Jan 1995 Jan 1996 Ancol Pumping Station Project, PT Wijaya Karya Superintendent



Name of Applicant


Job Title

Plant and Equipment Engineer


Name :


Date of birth :

May24th1979


Civil Engineering



Present employment




Achmad Harris



10 (Ten) Years

Job title: Plant and Equipment Engineer




Feb 13 Now Plant and Equipment Engineer of Construction of Merah Putih Bridge , Ambon – Maluku, PT.Wijaya Karya (Persero) Tbk


Sept 10 Jan 13 Plant and Equipment Engineer of Construction of Surabaya-Mojokerto Highway, PT.Wijaya Karya (Persero) Tbk.


July 09 Sept 10 Plant and Equipment Engineer of East West Motorway Algeria Project , PT.Wijaya Karya (Persero) Tbk.




July 08 July 09 Plant and Equipment Engineer of Road and Bridge PackageBP-07C Pamanukan – Eretan Kulon, West Java, PT.Wijaya Karya (Persero) Tbk


Aug 05 July 08 Plant and Equipment Engineer of road contruction Bongkong Nanga Tepuai Nanga Semangut Kalbar


Nov 04 Aug 05 Plant and Equipment Engineer of Highway construction of Simpang Perdau Batu Ampar II Kaltim


Aug 04 Nov 04 Plant and Equipment Engineer of road contruction long bangun Long Boh Long Nawang Kaltim




Name of Applicant

M. Yusrizal

Job Title

Quality Control Engineer


Name :

M. Yusrizal

Date of birth :

March 18th, 1964


Civil Engineering



Present employment




Achmad Harris



13 (Thirteen) Years

Job title:




From/ To Company/ Position

Project Relevant Technical/ Commercial/ Management Experience

July 2013 NowSamarinda- Balikpapan Freeway Construction Project, PT. Wijaya Karya (persero) Tbk

Quality Control

June 2011 June 2013New Acces Road to Gunung Putri , PT.Wijaya Karya (Persero) Tbk.

Quality Control

Oct 2010 May 2011Road Betterment Kundiwa to Gewa Project Chimbu Province Papua Nugini, PT.Wijaya Karya (Persero) Tbk.

Quality Control

Mar 2010 Sept 2010

improved runway and turning area with 7.5 cm thick hot mix including marking, airport Djalaludin gorontalo , PT.Wijaya Karya (Persero) Tbk.

Quality Control

Oct 2009 Mar 2010East West Motorway Algeria Project, PT.Wijaya Karya (Persero) Tbk.

Quality Control



Sep 2008 Sep 2009 USAID Road and Bridge Reconstruction and Rehabilitation Project, PT.Wijaya Karya (Persero) Tbk.

Quality Control

July 2007 Aug 2008East West motorway Algeria Project PT.Wijaya Karya (Persero) Tbk.

Quality Control

Dec 2006 June 2007Toll road project Cibitung Cikarang, PT.Wijaya Karya (Persero) Tbk.

Quality Control

Sep 2005 Nov 2006Airport Development Yogyakarta, PT.Wijaya Karya (Persero) Tbk.

Senior Engineer

Sep 2001 July 2004 Project Cikapayang Pasupati, PT.Wijaya Karya (Persero) Tbk.

Engineer staff



Name of Applicant

M. Yusrizal

Job Title



Name :

M. Yusrizal

Date of birth :

March 18th, 1964


Civil Engineering



Present employment




Achmad Harris



13 (Thirteen) Years

Job title:




From/ To Company/ Position

Project Relevant Technical/ Commercial/ Management Experience

July 2013 NowSamarinda- Balikpapan Freeway Construction Project, PT. Wijaya Karya (persero) Tbk

Quality Control

June 2011 June 2013New Acces Road to Gunung Putri , PT.Wijaya Karya (Persero) Tbk.

Quality Control

Oct 2010 May 2011Road Betterment Kundiwa to Gewa Project Chimbu Province Papua Nugini, PT.Wijaya Karya (Persero) Tbk.

Quality Control

Mar 2010 Sept 2010

improved runway and turning area with 7.5 cm thick hot mix including marking, airport Djalaludin gorontalo , PT.Wijaya Karya (Persero) Tbk.

Quality Control

Oct 2009 Mar 2010East West Motorway Algeria Project, PT.Wijaya Karya (Persero) Tbk.

Quality Control



Sep 2008 Sep 2009 USAID Road and Bridge Reconstruction and Rehabilitation Project, PT.Wijaya Karya (Persero) Tbk.

Quality Control

July 2007 Aug 2008East West motorway Algeria Project PT.Wijaya Karya (Persero) Tbk.

Quality Control

Dec 2006 June 2007Toll road project Cibitung Cikarang, PT.Wijaya Karya (Persero) Tbk.

Quality Control

Sep 2005 Nov 2006Airport Development Yogyakarta, PT.Wijaya Karya (Persero) Tbk.

Senior Engineer

Sep 2001 July 2004 Project Cikapayang Pasupati, PT.Wijaya Karya (Persero) Tbk.

Engineer staff

Name of Applicant

Untung Tri Uripto

Job Title

Chief Surveyor




Name :

Untung Tri Uripto

Date of birth : November 29th 1971


Civil Engineering


Chief Surveyor

Present employment




Achmad Harris



12 Years

Job title:

Chief Surveyor




Oct 2013 Now Chief Surveyor of Samarinda- Balikpapan Freeway Construction Project, PT. Wijaya Karya (persero) Tbk

Chief Surveyor

July 2012 Oct 2013Chief Surveyor of Bogor Outerring Road Construction Project, PT.Wijaya Karya (Persero) Tbk

Chief Surveyor

June2010 June 2012Chief Surveyor in Eastway Motorway Algeria Overseas Department, PT Wijaya Karya

Chief Surveyor

Janl 2007 June2010Chief Surveyor in Aceh Road Bridge Contruction and

Rehabilitation Project, PT Wijaya Karya

Chief Surveyor

May 2004 Dec 2006

Chief Surveyor in Cikubang bridge Construction Project,

PT Wijaya Karya

Chief Surveyor



Feb 2003 May 2004Chief Surveyor in Highway widening project Jagorawi

segment Cibinong Project

Chief Surveyor

Oct 2002 Feb 2003Surveyor in Pasteur Cikapayang Surapati Elevated Road

and Bridge project

Chief Surveyor

Name of Applicant

Yusril Amri



Job Title

Safety Engineer


Name :

Yusril Amri

Date of birth :

July4th 1972


Civil Engineering


Safety Engineer

Present employment




Achmad Harris



14 Years

Job title:

Safety Engineer



From to Project Relevant Technical/ Commercial/ Management

Experience

Dec 2014 Now Safety Engineer-PT WIJAYA KARYA Safety Engineer

Dec 2011 Jul 2014 Safety Engineer - Surabaya Mojokerto Toll Road Construction Project, PT WIJAYA KARYA

Safety Engineer

Aug 2008 Jan 2011 Safety Engineer - East / West Motorway Algeria Project, PT WIJAYA KARYA

Safety Engineer

Feb 2005 May 2008 Safety Engineer - Cikro Double Track Railroad Construction Project, Cirebon Kroya, PT WIJAYA KARYA

Safety Engineer

Dec 2001 Jul 2004 Safety Engineer - Suramadu Bridge Project, Aceh, PT WIJAYA KARYA

Safety Engineer

Name of Applicant

Siddik Widiarto Pramono



Job Title

Safety, Health & Environment Manager


Name : Siddik Widiarto Pramono Date of birth :

December 3rd , 1964


Civil Engineering



Present employment




Achmad Harris



21 Years

Job title:





Oct 2013 Now SHE Manager Samarinda- Balikpapan Freeway Construction Project, PT. Wijaya Karya (persero) Tbk

SHE Manager

Sep 2011 July 2013 SHE Manage of East West Motorway Algeria Project, PT.Wijaya Karya (Persero) Tbk.

SHE Manager

Feb 2010 Nov 2011 SHE Manager of S 1B P USAID Project, PT.Wijaya Karya (Persero) Tbk.

SHE Manager

Feb 2009 Jan 2010 SHE Manager of East West motorway Algeria Project PT.Wijaya Karya (Persero) Tbk.

SHE Manager

May 2007 Jan 2008 SHE Manager of the toll road project Cibitung Cikarang, PT.Wijaya Karya (Persero) Tbk.

SHE Manager



Aug 2005 Apr 2007 SHE Manager of Airport Development Yogyakarta, PT.Wijaya Karya (Persero) Tbk.

SHE Manager

Mar 2004 July 2005 SHE Manager, Contract Package no. MFC-2-of The Medan Flood Control Project ,PT Wijaya Karya

SHE Manager

Feb 2003 Feb 2004 Superintendant , The Twelve Province Bridge Replacement and Rehabilitation Project Package OR-29 Juragungting , PT Wijaya Karya

Superintentand

Aug 2001 Jan 2003 Supervisor, Construction of Highway and Bridge Arteri?Kolektor IPJP Fly Over, PT Wijaya Karya

Supervisor

May 1999 Jun 2001 SHE Officer Building Construction Division ,PT. Wijaya Karya SHE Officer

Mar 1997 Apr 1998 Quality Assurance Staff of KANDATEL BOGOR Project, Bogor ,PT. Wijaya Karya

Quality Assurance

May 1994 Feb 1996 Quality Assurance Staff of Building Construction Division ,PT. Wijaya Karya

Quality assurance



Date ……………………………………….



FORM J – PLANT / EQUIPMENT – OWNED OR LEASED




(List of Plant and Equipment Owned or Leased)

No Description (Type, Model, Year of Manufacture&

Size/Capacity)

Name of Company

(For JV Co only)

Indicate Owned / Leased

No of Units

Age(From Date of

initial purchase Registration)

Existing Storage Yard Remarks

1.

2.

3.

4.

5.

6.

7.

Launcher Gantry

Komatsu Hydraulic Excavator 0.93 m3

Komatsu Excavator 0.83 - 2 m3

Concrete truck mixer 6 m3

Motor Grader 3.73 m3, 135 HP

Dump truck 8-20 ton,12 m3

Bulldozer 150 HP, 15 ton, 20 ton

-

-

-

-

-

-

-

Owned

Owned

Owned

Owned

Owned

Owned

Owned

-

13

34

17

4

110

26

3

13

5

9

12

5

12

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Availiable and Worth to Operate









8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

Back pusher 1000 Kph

Water pumps 4" x 12", 6"x12"

Concrete Mixer 0.5 m3

Generator set 250, 150 Kva

Flat bed truck 5 ton

Laboratory and testing equipment Soil testing and concrete and concrete

Vibratory roller 15 ton

Water tank 4000 ltr

Portable concrete Mixer 0.5 m3 dan 0.27 m3

Concrete Bucket 1 m3

Concrete Vibrator 6 m

Welding Elect Drying Oven

-

-

-

-

-

-

-

-

-

-

-

-

Owned

Owned

Owned

Owned

Owned

Owned

Owned

Owned

Owned

Owned

Owned

Owned

6

28

35

5

8

4

1

4

2

11

3

12

12 & 11

7

7

9

16 & 17

14

3 & 4

6

7

7

7

12

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia















20.

21.

22.

23.

24.

25.

Hydraulic Jack

Crawler Crane 150 Ton

Forklift "Toyota” 2.5 Ton

Stamper 370x 300mm

Tower Crane 3.8 ton, JIB 55 M

Mobile Crane 25 ton

-

-

-

-

-

-

Owned

Owned

Owned

Owned

Owned

Owned

3

3

2

3

28

2

10

10

18

10

7

11

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia

Cikarang, Indonesia







Note: Please attach:(i) Certified true copies by the company Secretary/Grade A officer from a Government body of the registration cards and/or other proof of documents of

ownership/lease for each plant and equipment listed shall be submitted by the Applicant.



Date ……………………………………….



FORM K – QUALITY, SAFETY, HEALTH & ENVIRONMENTAL PLAN



Company's Name: PT. Wijaya Karya persero Tbk

Summary of Quality, Safety, Health & Environmental Plan

Item Description

Submission

(Please provide separate attachment, if necessary )

A Project Quality Assurance & Control System including on the following details:

1) a copy of the Company Quality Manual and policy statement

2) a copy of the Company ISO 9001 : 2008 Certificate

3) a copy of the Project Quality Plan from a past or recent project similar to this project scope of works

4) a detail description of Project Quality Control Program from a past or recent project similar to this project scope of works

5) List of proposed quality management system procedures intended for the project

B Safety & Health Plan include details of the proposed safety & health control processes to prevent and protect the safety of the employee, subcontractors, public, property and all parties who involved with the work activities. The Applicants shall submit the following:

1) Safety & Health Policy Statement

2) OHSAS 18001 : 2007 or MS 1722 : 2005 certification

3) Safety & Health Plan

4) Emergency Response Plan

5) Safety & Health Organization chart and detail of responsible person who have full authority to ensure the implementation of safety & health requirements.

6) List of applicable Safety & Health Control Procedures and related Instructions related to the project scope of work

7) Hazard or Risk Register

8) Safety & Health Performance Record for the past 5 years on safety & health violation issued by local authority, loss time injury, incident statistic, total man-hour, severity and frequency rate



FORM K – QUALITY, SAFETY, HEALTH & ENVIRONMENTAL PLAN (CONT’D)

C Environmental Requirements:

1) Environmental Management System Manual and Policy statement

2) ISO 14001 : 2004 certificate

3) Environmental department organization chart and detail of responsible person who have full authority to ensure the implementation of environmental requirements.



4) Environmental management and control procedures

5) Company environmental performance record for the past 5 years


Name in Full ………………………………………..(Authorized Representative)



Designation ………………………………………..

Date ……………………………………….



FORM L – LITIGATION (CURRENT & LAST 10 YEARS)



Company's Name: ..........................................................................................................................................

(Applicants should provide information on any history of litigation or arbitration resulting from contracts executed for the last five years or currently under execution)



YearAward For/

AgainstApplicant

NameOf

Employer

Cause of

Litigation

Matter in

Dispute

Final Contract Amount

(RM)

Disputed Amount

(RM)



(Applicants should provide information on any historical non-performance of any projects)

Item Historical Contract Non-Performance

Details Year

1 Termination of Contract by Employer

2 Blacklist by the registration



authorities or the Employer


Name in Full ………………………………………..



(Authorized Representative) Designation ………………………………………..

Date ………………………………………. (This form shall be filled by the Project Architect/Engineer who supervises the project and shall be handed over to the Applicant in a sealed envelope for his submission together with the Pre-Qualification Document.)



CONFIDENTIAL

FORM M - REPORT BY PROJECT ARCHITECT/ENGINEER ON CONTRACTOR'S PERFORMANCE ON CURRENT PROJECTS



To :



Mass Rapid Transit Corporation Sdn Bhd Level 5, Menara I & P1 No. 46, Jalan DungunBukit Damansara50490 Kuala LumpurMalaysia

Contractor of the Project: PT Wijaya Karya (Persero) Tbk



Name of the On-Going Project: ……………….

………………………………………………………………………………………………………………………………………………………………………

………………………

Contract No.

Contract Sum (including estimated variation works) : RM ................................................

Prime Cost and Provisional Sums: RM ................................................

Value of Builder's Works: RM ................................................



Date of Commencement: .......................................................Contract Period:.........................weeks/months

Original Date for Completion:...........................................................................................................................

Approved Extension of Time (EOT):..................................................................days

EOT being considered/to be considered:..........................................................days

Reasons:

(I) ........................................................................................................................................................................................



(ii) .....................................................................................................................................................................



CONFIDENTIAL

FORM M - REPORT BY PROJECT ARCHITECT/ENGINEER ON CONTRACTOR'S PERFORMANCE ON CURRENT PROJECTS (CONT'D)



Progress of works (based on the latest Interim Payment)



Actual Progress:......................% Scheduled:……………%

Proposed Completion Date:.............................................................

Value of works completed:……………………………………………………

Value of remaining works to be completed:………………………………………………………..



Comments on Contractor's Performance(State any merits/weaknesses of the contractor for any action taken/to be taken in connection with the contractor's performance in execution of the works)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Architect's/ Engineer's…………………………………………………………MRTCORP/KVMRT-SBK/CW/35/105-2015


(Signature)

Name:……………………………………………

Designation:…………………………………….

Name and Addressof Architect/Engineer :……………………………………………

:…………………………………………..

Date :…………………………………………….



Telephone No. :…………………………………………….

(This form shall be filled by the Project Architect/Engineer who supervised the project and shall be handed over to the Applicant in a sealed envelope for his submission together with the Pre-Qualification Document.)



CONFIDENTIALFORM N - REPORT BY PROJECT ARCHITECT/ENGINEER ON CONTRACTOR'S

PERFORMANCE ON COMPLETED PROJECTS





To : Mass Rapid Transit Corporation Sdn Bhd Level 5, Menara I & P1 No. 46, Jalan DungunBukit Damansara50490 Kuala Lumpur Malaysia

Contractor of the Project: …………………………………………………………………………………



Name of the Completed Project: ……………….

……………………………………………………………………………………………………………………………………………

……………………………………………………

…………………………………………………………………………………………………….…

Contract No. :…………………………………

Contract Sum (including estimated variation works): RM ........................................



Prime Cost and Provisional Sums: RM ........................................

Final Contract Sums: RM ........................................

Date of Commencement:...................................Contract Period:................weeks/months

Original Date for Completion ...............................................................................................

Extension Date of Completion:………………………………………………….



Actual Date of Completion:................................................................



CONFIDENTIALFORM N - REPORT BY PROJECT ARCHITECT/ENGINEER ON CONTRACTOR'S PERFORMANCE

ON COMPLETED PROJECTS (CONT'D)



Comments on Contractor's Performance



(State any merits/weaknesses of the contractor for any action taken/to be taken in connection with the contractor's performance in execution of the works)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Architect's/ Engineer's…………………………………………………………(Signature)



Name:……………………………………………

Designation:…………………………………….

Name and address :…………………………………………….

of Architect/Engineer :…………………………………………..

……………………………………………

……………………………………………



……………………………………………

Date :…………………………………………….

Telephone No. :…………………………………………….



FORM O - PARENT COMPANY GUARANTEE



[Letterhead of company’s parent company including full postal address, telephone no., fax no. and email address]



To :

Mass Rapid Transit Corporation Sdn Bhd Level 5, Menara I & P1 No. 46, Jalan DungunBukit Damansara50490 Kuala Lumpur Malaysia

PARENT COMPANY GUARANTEE

Particulars



Date of issue: September 17, 2015

PDP: MMC GAMUDA KVMRT (PDP) SDN BHDGuarantor: PT Wijaya Karya (Persero) Tbk a company duly incorporated under the laws of

Indonesia, whose business address is Jl. D.I. Panjaitan, Kav. 9 (“Guarantor”)

Applicant: PT Wijaya Karya (Persero) Tbk a company duly incorporated under the laws of Indonesia, whose business address is Jl. D.I.Panjaitan, Kav.9 (“Applicant”)

Project: Projek Mass Rapid Transit Lembah Kelang: Jajaran Sungai Buloh – KajangWorks: Proposed Construction and Completion of Pasar Seni Paid Link and Other

Associated Works between Existing Pasar Seni LRT Station and Kuala Lumpur KTM



Station (“Works”)

The Guarantor hereby irrevocably and unconditionally guarantees and undertakes to MRT Corp/PDP and its successors and assigns as follows:

1. The due, proper and punctual performance, observance and compliance by the Applicant of each and every terms, provisions, conditions, duties, requirements, responsibilities, works and undertakings whether expressly or impliedly made in the Works as may, from time to time, be amended.

2. The Guarantor agrees to any amendment, modification, variation or supplemental made to the Works, the due performance and compliance thereof by the Applicant is likewise herein guaranteed.



3. The Applicant shall properly, diligently and with all reasonable care and skill, carry out and complete all of the Works.

4. To pay MRT Corp/PDP all sums which are or may be due and owing by the Applicant which arise out of, or is in connection with or in relation to the Works upon the Applicant’s failure or refusal to pay, and irrespective of whether a demand is made or not.

FORM O - PARENT COMPANY GUARANTEE (CONT’D)



5. All losses and expenses which are incurred by MRT Corp/PDP as a result of any act, default, neglect, omission or failure of the Applicant to perform the Works shall be paid by the Guarantor on demand.

6. The Guarantor shall provide as its own cost and expenses the necessary support services (including but not limited to such personnel, administration, technical services and financial back-up) which the Applicant may require from time to time to discharge the Works.

7. In the event the Works is terminated, the Guarantor shall provide MRT Corp/PDP the necessary support services (as stated above) at no cost, unless the determination of the Works was not due to the Applicant’s default, negligence or failure.



8. All sums payable by the Guarantor under this guarantee shall be paid in full without set off, counter claim, condition or qualification of any nature whatsoever.

9. The Guarantor further agrees that the undertaking given herein shall be performed immediately without need for MRT Corp/PDP to take legal action against or obtain consent of the Applicant, without further proof and notwithstanding any protest/objection by the Applicant or the Guarantor.

10. The Guarantor’s undertaking and guarantee under this guarantee shall not be discharged or released by any act, omission, matter or thing which might operate to release or otherwise exonerate the Guarantor from its works hereunder in whole or in part, including without limitation, by any alteration as to time, performance, works or arrangement with the Applicant by MRT Corp/PDP; or by any forbearance by MRT Corp/PDP whether as to payment, time, performance or otherwise; or by any



illegality, frustration or unenforceability of any provision; or by any bond, undertaking, security or other guarantee held or obtained by MRT Corp/PDP.

11. The Guarantor agrees that this guarantee shall be construed in accordance with the laws of Malaysia and shall submit to the exclusive jurisdiction of the courts of Malaysia.

12. This Guarantee and the benefit conferred by it may be assigned by MRT Corp/PDP at any time.

13. This Guarantee shall be irrevocable and shall remain in force for a period of two (2) years from the date of issue.



IN WITNESS WHEREOF this guarantee has been executed on the date set out above

The Common Seal ofPT Wijaya Karya (Persero) TbkWas hereby affixed in the presence of:

................................................ ..................................................... Director Director /SecretaryMRTCORP/KVMRT-SBK/CW/35/105-2015


FORM P - APPLICANTS’ LETTER OF RECOGNITION



[Letterhead of the Company/ Consortium/ JV including full postal address, telephone no., fax no. and email address]

For



Pre-Qualification Application for the Proposed Construction and Completion of Pasar Seni Paid Link and Other Associated Works between Existing Pasar Seni LRT Station and Kuala Lumpur KTM Station for Projek Mass Rapid Transit Lembah Kelang: Jajaran Sungai Buloh – Kajang

I…………...................................................NRIC No............................................................…the personnel representing..............................Registration number..............................hereby solemnly declare that I and/or any other personnel representing the Company shall not offer or give bribes to any individual in Mass Rapid Transit Corporation Sdn Bhd and Project Delivery Partner or any other individual, as a bribe for the purpose of being selected in the pre-qualification as mentioned above. A Letter of Delegation of Power is appended



herewith authorising the abovenamed personnel to represent the Company as stated above to make this declaration.

2. If I or any personnel representing the Company is found guilty of offering or giving ribes to any individual in Mass Rapid Transit Corporation Sdn Bhd and Project Delivery Partner or any other individual as bribe for the purpose of being selected in the pre-qualification as above mentioned, then I as the representative of the Company hereby consent and agreed to the following actions to be taken against the Company:

2.1 revocation of the contract offered for the above pre-qualification; or2.2 termination of the contract for the above pre-qualification; and2.3 other disciplinary action in accordance with Government procurement regulations.



3. Any individual attempting to seek bribe from me and/or by any individual associated with the Company for the purpose of being selected in this pre-qualification as above mentioned, then I undertake to promptly report the said action to the Office of The Malaysia Anti-Corruption Commission or to the nearest Police Station.

Yours Sincerely,

…………………………….....................Name:NRIC:MRTCORP/KVMRT-SBK/CW/35/105-2015


Company Stamp :



FORM Q – DETAILS OF CONTRACTUAL RELATIONSHIP BETWEEN MEMBERS OF JOINT VENTURE OR CONSORTIUM




PROJEK MASS RAPID TRANSIT LEMBAH KELANG: Pre-Qualification DocumentJAJARAN SUNGAI BULOH – KAJANG (SBK) Pasar Seni Paid Link Package

APPENDIX 1



FORM A



FORM B



FORM C



FORM D



FORM E



FORM F



FORM G



FORM H



FORM I



FORM J



FORM K



FORM L



FORM M



FORM N



FORM O



FORM P



FORM Q


Pre qualification document (pasar seni link) new

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