Appendix to Regulation of the Head of the Commodity Futures Trading Regulatory Agency Number 04/BAPPEBTI/PER-SRG/7/2007

MODEL FORM NUMBER: SRG-LPK01

Number: ............... , ...........................20....
Attachment:
Subject: Application for Approval as a
Conformity Assessment Body in the Warehouse Receipt System

……………………………………
To:
The Head of the Commodity Futures Trading Regulatory Agency in J A K A R T A

Hereby, we, the undersigned as Head/Chief Executive Officer of the Conformity Assessment Body ……………, acting on behalf of and in the name of ………………...................., submit an application to obtain Approval as a Conformity Assessment Body in the Warehouse Receipt System.

As supporting material for consideration, we attach the following supporting documents:

1. List of Complete Documents for the Application for Approval as a Conformity Assessment Body (Appendix 1 of Model Form Number SRG-LPK01);
2. Application Form for Approval as a Conformity Assessment Body (Appendix 2 of Model Form Number SRG-LPK01).

We submit this application and thank you for your attention.

..........................................,20......
Applicant,
(Clear Name)
...............................................
(Head/Chief Executive Officer)*)
*) Choose one

Appendix 1 of Model Form Number: SRG-LPK01
LIST OF COMPLETE DOCUMENTS FOR THE APPLICATION FOR APPROVAL AS A CONFORMITY ASSESSMENT BODY IN THE WAREHOUSE RECEIPT SYSTEM

No	Document	Yes	No

1. | Photocopy of legal documents of the Conformity Assessment Body; | |
2. | Organizational structure and personnel list of the Conformity Assessment Body; | |
3. | List of relevant laboratories (if any); | |
4. | Accreditation certificate including the scope of accreditation; | |
5. | Example of conformity assessment certificate. | |

Appendix 2 of Model Form Number: SRG-LPK01
APPLICATION FORM FOR
APPROVAL AS A CONFORMITY ASSESSMENT BODY
IN THE WAREHOUSE RECEIPT SYSTEM

1. Applicant Name: ................................................................................
2. Identity Number: ................................................................................
   (ID Card/Passport)*)
3. Applicant Position: ................................................................................
4. Applicant Address: ................................................................................
   ................................................................................
   (Street Name & Number)
   ..................................... -  (City & Postal Code)
5. Name of Conformity Assessment
   Body: .................................................................
6. Address of Conformity Assessment
   Body: .................................................................
   .................................................................
   (Street Name & Number)
   ..................................... -  (City & Postal Code)
7. Telephone Number, e-mail
   and Fax: .................................................................
8. Scope of Conformity
   Assessment Held: ..................................................................
   ................................................................
   ................................................................
   ................................................................
   ................................................................
   ..........................................,20......
   Applicant,
   (Company Stamp)
   (Clear Name)
   ...............................................
   (Head/Chief Executive Officer)*)
   *) Choose one

MODEL FORM NUMBER: SRG-LPK02
DECISION
OF THE HEAD OF THE COMMODITY FUTURES TRADING REGULATORY AGENCY NUMBER ……………………………………….. REGARDING APPROVAL AS A CONFORMITY ASSESSMENT BODY IN THE WAREHOUSE RECEIPT SYSTEM TO …………………………….

THE HEAD OF THE COMMODITY FUTURES TRADING REGULATORY AGENCY,

Reading: The Application for Approval as a Conformity Assessment Body in the Warehouse Receipt System submitted by Conformity Assessment Body ...……………........ Number …………… dated ……………;

Considering: That the application has met the requirements and therefore can be considered for granting Approval as a Conformity Assessment Body in the Warehouse Receipt System;

Recalling:

1. Law Number 32 of 1997 on Commodity Futures Trading (State Gazette of the Republic of Indonesia Year 1997 Number 93, Supplement to the State Gazette of the Republic of Indonesia Number 3720);
2. Law Number 9 of 2006 on the Warehouse Receipt System (State Gazette of the Republic of Indonesia Year 2006 Number 59, Supplement to the State Gazette of the Republic of Indonesia Number 4630);
3. Government Regulation Number 102 of 2000 on National Standardization (State Gazette of the Republic of Indonesia Year 2000 Number 199, Supplement to the State Gazette of the Republic of Indonesia Number 4020);
4. Government Regulation Number 36 of 2007 on the Implementation of Law Number 9 of 2006 on the Warehouse Receipt System (State Gazette of the Republic of Indonesia Year 2007 Number 79, Supplement to the State Gazette of the Republic of Indonesia Number 4735);
5. Presidential Decree of the Republic of Indonesia Number 34/M of 2005 on the Appointment of Echelon I Officials in the Environment of the Ministry of Trade;
6. Regulation of the Head of the Commodity Futures Trading Regulatory Agency Number 04/BAPPEBTI/PER-SRG/07/2007 on Requirements and Procedures for Obtaining Approval as a Conformity Assessment Body;

D E C I D E S:

Establishing: THE DECISION OF THE HEAD OF THE COMMODITY FUTURES TRADING REGULATORY AGENCY REGARDING APPROVAL AS A CONFORMITY ASSESSMENT BODY IN THE WAREHOUSE RECEIPT SYSTEM TO …………………………….

Article 1
Granting Approval as a Conformity Assessment Body in the Warehouse Receipt System to ................... (full name of Conformity Assessment Body) with address at .........…… (full address of Conformity Assessment Body) and responsible person ............. position .............

Article 2
This Approval is valid as long as the concerned party is still actively carrying out activities according to its function as referred to in Article 1.

Article 3
This Decision of the Head of the Commodity Futures Trading Regulatory Agency takes effect from the date of establishment.

Established in Jakarta on the date

HEAD OF THE COMMODITY FUTURES TRADING REGULATORY AGENCY, …………………………….

Copy to:

1. Minister of Trade of the Republic of Indonesia;
2. Secretary General of the Ministry of Trade;
3. Inspector General of the Ministry of Trade;
4. Director General of Domestic Trade;
5. Director General of Foreign Trade;
6. Echelon II Officials in the Bappebti environment;
7. Head of Local Trade Office;
8. For record.

MODEL FORM NUMBER: SRG-LPK03

Number: Jakarta, ...........................20....
Attachment: ---
Subject: Rejection of Application for Approval as a Conformity Assessment Body

To:
……………………. in
...............................

Referring to your letter Number: ...................... dated ........................
regarding ..................................., after examining your application, it is hereby decided that your application is rejected because it does not meet the following requirements:

1. .............................................................................................................
2. .............................................................................................................
3. .............................................................................................................

We hope you understand.

HEAD OF THE COMMODITY FUTURES TRADING REGULATORY AGENCY,
.........................................

Copy to:

1. Minister of Trade of the Republic of Indonesia;
2. Secretary General of the Ministry of Trade;
3. Inspector General of the Ministry of Trade;
4. Director General of Domestic Trade;
5. Director General of Foreign Trade;
6. Echelon II Officials in the Bappebti environment;
7. Head of Local Trade Office;
8. For record.

MODEL FORM NUMBER: SRG-LPK04

Number: Jakarta, ...........................20....
Attachment: ---
Subject: Application for Change of Name and/or Address *) of Conformity Assessment Body
........................................................

To:
The Head of the Commodity Futures Trading Regulatory Agency in J A K A R T A

Hereby we submit a report on the change of name and/or address*) of Conformity Assessment Body .............

As supporting material for consideration, we attach the following supporting documents:

1. List of Complete Documents for the Change of Name and/or Address *) of Conformity Assessment Body (Appendix 1 of Model Form Number SRG-LPK04);
2. Application Form for the Report on the Change of Name and/or Address *) of Conformity Assessment Body (Appendix 2 of Model Form Number SRG-LPK04).

We submit this application and thank you for your attention.

......................, .......................20.....
Reporter
(Clear Name)
...............................................
(Head/Chief Executive Officer)*)

Copy to:

1. Minister of Trade of the Republic of Indonesia;
2. Secretary General of the Ministry of Trade;
3. Inspector General of the Ministry of Trade;
4. Director General of Domestic Trade;
5. Director General of Foreign Trade;
6. Echelon II Officials in the Bappebti environment;
7. Head of Local Trade Office;
8. For record.
   *) Choose one

Appendix 1 of Model Form Number: SRG-LPK04
LIST OF COMPLETE DOCUMENTS
FOR THE CHANGE OF NAME AND/OR ADDRESS*)
OF CONFORMITY ASSESSMENT BODY

No	Document	Yes	No

1. | Photocopy of legal documents of the Conformity Assessment Body; | |
2. | Organizational structure and personnel list of the Conformity Assessment Body; | |
3. | List of relevant laboratories (if any); | |
4. | Accreditation certificate including the scope of accreditation; | |
5. | Example of conformity assessment certificate. | |
   *) Choose one

Appendix 2 of Model Form Number: SRG-LPK04
APPLICATION FORM FOR THE REPORT
ON THE CHANGE OF NAME AND/OR ADDRESS *) OF CONFORMITY ASSESSMENT BODY

1. Reporter Name: .................................................................

2. Identity Number: ..............................................................
   (ID Card/Passport)*)

3. Reporter Position: .................................................................

4. Reporter Address: .................................................................
   .................................................................
   (Street Name & Number)
   ..................................... -  (City & Postal Code)

5. Company Name: Old.................................................................
   New..................................................................

6. Taxpayer Identification Number (NPWP): .................................................................

7. Company Address: Old .................................................................
   New...................................................................

8. Telephone Number, e-mail
   and Fax: Old .................................................................
   New....................................................................
   ..........................................,20......
   Applicant,
   (Clear Name)
   ...............................................
   (Position)
   *) Choose one

MODEL FORM NUMBER: SRG-LPK05

Number: Jakarta, ...........................20....
Attachment: ---
Subject: Report on Change of Management of Conformity Assessment Body
........................................................

To:
The Head of the Commodity Futures Trading Regulatory Agency in J A K A R T A

Hereby, we, the undersigned acting on behalf of and in the name of Conformity Assessment Body....................., submit a report on the change of management of Conformity Assessment Body ..................

As supporting material for consideration, we attach the following supporting documents:

1. List of Complete Documents for the Report on Change of Management of Conformity Assessment Body (Appendix 1 of Model Form Number SRG-LPK05);
2. Application Form for the Report on the Change of Management of Conformity Assessment Body (Appendix 2 of Model Form Number SRG-LPK05).

We submit this report and thank you for your attention.

Reporter,
(Clear Name)
..............................................
(Position)

Appendix 1 of Model Form Number: SRG-LPK05
LIST OF COMPLETE DOCUMENTS FOR THE REPORT
ON CHANGE OF MANAGEMENT OF CONFORMITY ASSESSMENT BODY

No	Document	Yes	No

1. | Photocopy of legal documents of the Conformity Assessment Body; | |
2. | Organizational structure and personnel list of the Conformity Assessment Body. | |

Appendix 2 of Model Form Number: SRG-LPK05
APPLICATION FORM FOR THE REPORT
ON CHANGE OF MANAGEMENT OF CONFORMITY ASSESSMENT BODY

1. Applicant Name: .................................................................
2. Identity Number: ..............................................................
   (ID Card/Passport)*)
3. Applicant Position: .................................................................
4. Applicant Address: .................................................................
   .................................................................
   (Street Name & Number)
   ..................................... -  (City & Postal Code)
5. Company Name: .................................................................
6. Taxpayer Identification Number (NPWP): ...-
7. Capital:)
   a. Authorized Capital: .................................................................
   b. Paid-up Capital: .................................................................
8. Company Address: .................................................................
   .................................................................
   (Street Name & Number)
   ..................................... -  (City & Postal Code)
9. Telephone Number, e-mail
   and Fax: .................................................................
   .........................., ......................20....
   Applicant,
   (Clear Name)
   ...............................................
   (Head/Chief Executive Officer)*)
   *) Choose one
   ) Not required if the Conformity Assessment Body is a state institution.

MODEL FORM NUMBER: SRG-LPK06

Number: Jakarta, ...........................20....
Attachment: ---
Subject: Report on Change of
Scope of Conformity
Assessment of Conformity
Assessment Body

To:
The Head of the Commodity Futures Trading Regulatory Agency in J A K A R T A

Hereby we submit a report on the Change of Scope of Conformity Assessment of Conformity Assessment Body ................. .

As supporting material for consideration, we attach the following supporting documents:

1. List of Complete Documents for the Report on Change of Scope of Conformity Assessment Body (Appendix 1 of Model Form Number SRG-LPK06);
2. Application Form for the Report on the Change of Scope of Conformity Assessment Body (Appendix 2 of Model Form Number SRG-LPK06).

We submit this report and thank you for your attention.

......................, .......................20.....
Reporter,
(Clear Name)
...............................................
(Head/Chief Executive Officer)*)

Copy to:

1. Minister of Trade of the Republic of Indonesia;
2. Secretary General of the Ministry of Trade;
3. Inspector General of the Ministry of Trade;
4. Director General of Domestic Trade;
5. Director General of Foreign Trade;
6. Echelon II Officials in the Bappebti environment;
7. Head of Local Trade Office;
8. For record.
   *) Choose one

Appendix 1 of Model Form Number: SRG-LPK06
LIST OF COMPLETE DOCUMENTS
FOR THE REPORT ON CHANGE OF SCOPE OF CONFORMITY ASSESSMENT OF CONFORMITY ASSESSMENT BODY

No	Document	Yes	No

1. | Organizational structure and personnel list of the Conformity Assessment Body; | |
2. | List of relevant laboratories (if any); | |
3. | Accreditation certificate including the scope of accreditation; | |
4. | Example of conformity assessment certificate. | |

Appendix 2 of Model Form Number: SRG-LPK06
APPLICATION FORM FOR THE REPORT
ON CHANGE OF SCOPE OF CONFORMITY ASSESSMENT
OF CONFORMITY ASSESSMENT BODY
(FILLED ACCORDING TO ACCREDITATION FROM THE NATIONAL ACCREDITATION COMMITTEE)

1. Applicant Name: .................................................................
2. Identity Number: .................................................................
   (ID Card/Passport)*)
3. Applicant Position: .................................................................
4. Applicant Address: .................................................................
   .................................................................
   (Street Name & Number)
   ..................................... -  (City & Postal Code)
5. Name of Conformity Assessment
   Body: .................................................................
6. Company Address: .................................................................
   .................................................................
   (Street Name & Number)
   ..................................... -  (City & Postal Code)
7. Telephone Number and
   Fax: .................................................................
8. Scope of Conformity
   Assessment Before
   Change: ..................................................................
   ..................................................................
   ..................................................................
   ..................................................................
   ..................................................................
9. Scope of Conformity
   Assessment After
   Change: ..................................................................
   ..................................................................
   ..................................................................
   ..................................................................
   ..................................................................
   ..........................................,20......
   Applicant,
   (Company Stamp)
   (Clear Name)
   ...............................................
   (Position)
   *) Choose one