CONTOH SURAT PERMOHONAN SURAT IZIN USAHA PERDAGANGAN (MIKRO/KECIL/MENENGAH/BESAR*)

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SURAT PERMOHONAN SURAT IZIN USAHA PERDAGANGAN
(MIKRO/KECIL/MENENGAH/BESAR*)

DIISI OLEH PEMILIK /PENGURUS /PENANGGUNG JAWAB
Diisi/diketik dengan huruf cetak

                                                                                                           Kepada
                                                                                                          Yth. Kepala Badan Pelayanan Perijinan
                                                                                                                    Kota Probolinggo
                                                                                                          di
                                                                                                                    PROBOLINGGO

Yang bertanda tangan dibawah ini mengajukan permohonan Surat Izin Usaha Perdagangan (Mikro/Kecil/Menengah/Besar*) sebagaimana dimaksud dalam Peraturan Menteri Perdagangan RI No. 46/IV/DAG/9/2009.

1.       Permohonan SIUP Baru                                                                                                                                        :

2.       Permohonan pendaftaran Ulang. Perubahan  dan atau Penggantian SIUP*)                 :

I. Identitas Pemilik/Pengurus/Penanggungjawab


1. Nama                                               : .............................................................

2. Alamat tempat tinggal               : .............................................................

3. Tempat/tanggal lahir                 : .............................................................

4. Nomor Telp. Fax.                         : .............................................................

5. Nomor KTP/Paspor                    : .............................................................

6. Kewarganegaraan                       : ............................................................. 

II. Identitas Perusahaan

1. Nama Perusahaan                      : .............................................................

2. Alamat Perusahaan                    : .............................................................

3. Nomor Telp./Fax                         : .............................................................

4. Provinsi                                           : .............................................................

5. Kabupaten / Kota                        : .............................................................

6. Kecamatan                                     : .............................................................

7. Kelurahan / Desa                         : .............................................................

8. Status                                               : PMA/PMD/Lain-lain*)

9. Kode Pos                                        :                                              

III.LigelitasPerusahaan                                                                                                                                          

Perusahaan berbentuk Perseroan Terbatas/Koperasi/CV/Firma*)

1.       Akta Pendirian

a. Nomor & Tgl. Akta                              : .............................................................

b. Nomor & Tgl. Pengesahan              : ..............................................................

2.       Akta Perubahan

a. Nomor & Tgl. Akta                              : .............................................................

b. Nomor & Tgl. Pengesahan              : ..............................................................

 IV. Kekayaan Bersih dan Saham

1. Nilai kekayaan bersih Perusahaan
    (tidak termasuk tanah dan bangunan tempat usaha)                                               : ..........................................................

2. Saham (khusus untuk Penanaman Modal Asing)

a. Total Nilai Saham                                                                                                             : ..........................................................

b. Komposisi Kepemilikan Lahan

    - Nasional                : .................... %

    - Asing                      :  .................... %

V. Kegiatan usaha

1. Kelembagaan                                                : ..........................................................

2. Kegiatan usaha (KLBI 4 digit)   : ..........................................................

3. Barang/jasa dagangan utama : ..........................................................

Demikian Surat permohonan SIUP ini kami buat dengan sebenarnya dan apabila dikemudian hari ternyata data/informasi dan keterangan tersebut tidak benar, maka kami menyatakan bersedia dibatalkan SIUP yang telah kami miliki dan dituntut dengan ketentuan peraturan perundang-undagan.

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

                                                                                                                                                                                Nama dan Tanda Tangan                                                                                                                                                                        Pemilik/Pengurus/Penanggungjawab                                                                                                                                                                                 Perusahaan Perdagangan

                                                                                                                                                                               

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

Catatan:
*) Coret yang tidak perlu

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