Vendor Application Form

Please complete & return to your Zoetis Contact

COMPANY ADDRESS ORDERING ADDRESS PAYMENT ADDRESS

(Headquarters; No P.O. Boxes) Same as Company Address Same as Company Address

* Name : Universitas Airlangga

Jl. Airlangga No. 4-6, Mulyorejo, Jawa

* Address :
Timur 60115, Indonesia
* City: Surabaya
* State/Country: Indonesia
PO Box
* Post Code 60115
* Region: Jawa Timur

Communication
* Language Bahasa Indonesia
* Standard Communication Method: Email (Fax, Email, Post, EDI, or ASN)

Bank Details Tax Information

Bank Name BCA Tax ID:
Bank Country Indonesia VAT Registration Number:
Bank key ( Sort Code, ABN) If Tax ID not Provided, Reason:
Swift Code
Bank account Name: Alycius Noveno Pieter Riantama
Bank account No: 8161055883
Bank Control Key / Type: Savings (Checking / Savings)
IBAN
Purchasing Information Finance Details
Supplier Contact name (For PO): * Accounts Receivable Contact Name: Alycius Noveno Pieter Riantama
Telephone Contact No. * Telephone Contact No. 08970406655
E-mail for Purchase Order * Contact e-mail address: noveno.pieter@gmail.com
Fax No.for Purchase Order Contact Fax No.
Currency

Zoetis Standard Payment Terms are 60 days

Note: * Fields are mandatory

I certify that the information provided above is true and accurate

Authorized Supplier Signature
Print Name Alycius Noveno Pieter Riantama