Version 1.

0 release date 10th Dec 2012

Effective Jul 22nd, 2015

NEW PAYMENT REQUEST FORM

(For Payment Associated with Promotional Activities due to third parties where no Purchase Order is issued)

General Company Code : 6700 PT MSD Indonesia

Information
Vendor No : 5004835
Note : If Vendor No is not found in the Vendor List, please Fill in Vendor Request Form and send to Finance.
Vendor Name : dr. Komang Tonika,SpOG

Invoice Date : 6/3/2016 (DD/MM/YYYY) Currency : IDR

Invoice Reference #: XAIJA-M4PYFT

Event & Product Event Type : RTD Event Date : 6-Mar-16 (DD/MM/YYYY)
information
Event Name : RTD GRD AYAHBUNDA Location : KLINIK AYAHBUNDA

Event ID : XAIJA-M4PYFT

Product 1 : GARDASIL Split % 100% SAP Cost Center J20000MHPV

Please fill in the Product 2 : Split % SAP Cost Center #N/A

product using drop
down list
Product 3 : Split % SAP Cost Center #N/A
Note : If SAP Cost Center
"#N/A" Finance will reject the
requested Product 4 : Split % SAP Cost Center #N/A

Product 5 : Split % SAP Cost Center #N/A

Total split% 100%

(Total should be 100%)

Payment Description: RTD RTD GRD AYAHBUNDA

Payment Details After WHT Before WHT

Type of payments Amount IDRs Amount IDRs Reference Key 3: SAP GL Account
SPEAKER FEE 2,061,856 2,000,000 AEGA-7VF55U #N/A
Please fill in the payment
using drop down list #N/A #N/A
Note : If SAP GL Account "#N/A" #N/A #N/A
Finance will reject the requested
#N/A #N/A

Total Amount : 2,061,856

Requestor Request Date : 23-Jul-20

information
Requestor Name : Agnes KH Wardhani

Requestor Email ID : agnes.kusuma.herna.wardhani@merck.com

Requestor Signature :
 Version 1.0 release date 10th Dec 2012

AIJA-HR9PO0
 NEW PAYMENT REQUEST FORM
(For Payment Associated with Promotional Activities due to third parties where no P

General Company Code : 6700 PT MSD Indonesia

Information
Vendor No : 5004849
Note : If Vendor No is not found in the Vendor List, please
Vendor Name : dr. Dedianto Hidajat,SpKK

Invoice Date : 11/3/2016 (DD/MM/YYYY) Currency :

Invoice Reference #: XAIJA-M99S8J

Event & Product Event Type : LAYMEN SYMPOSIUM Event Date : 11-Mar-16
information
Event Name : LS GRD SELAGALAS Location : Gedung Pemuda Mataram

Event ID : XAIJA-M99S8J

Product 1 : GARDASIL Split % 100%

Please fill in the Product 2 : Split %

product using drop
down list
Product 3 : Split %
Note : If SAP Cost Center
"#N/A" Finance will reject the
requested Product 4 : Split %

Product 5 : Split %

Total split% 100%

(Total should be 100%)

Payment Description: LAYMEN SYMPOSIUM LS GRD SELAGALAS

Payment Details After WHT

Type of payments Amount IDRs
SPEAKER FEE 2,061,856
Please fill in the payment
using drop down list
Note : If SAP GL Account "#N/A"
Finance will reject the requested
 Please fill in the payment
using drop down list
Note : If SAP GL Account "#N/A"
Finance will reject the requested

Total Amount : 2,061,856

Requestor Request Date : 23-Jul-20

information
Requestor Name : Agnes KH Wardhani

Requestor Email ID : agnes.kusuma.herna.wardhani@merck.com

Requestor Signature :
 Effective Jul 22nd, 2015

T REQUEST FORM
due to third parties where no Purchase Order is issued)

dor No is not found in the Vendor List, please Fill in Vendor Request Form and send to Finance.

IDR

11-Mar-16 (DD/MM/YYYY)

Gedung Pemuda Mataram

100% SAP Cost Center J20000MHPV

SAP Cost Center #N/A

SAP Cost Center #N/A

SAP Cost Center #N/A

SAP Cost Center #N/A

100%

Before WHT
Amount IDRs Reference Key 3: SAP GL Account
2,000,000 AIJA-IASBX1 #N/A
#N/A #N/A
#N/A #N/A
#N/A #N/A
 NEW PAYMENT REQUEST FORM
(For Payment Associated with Promotional Activities due to third parties where no P

General Company Code : 6700 PT MSD Indonesia

Information
Vendor No : 5004785
Note : If Vendor No is not found in the Vendor List, please
Vendor Name : dr. Ariana,SpKK

Invoice Date : 7/3/2016 (DD/MM/YYYY) Currency :

Invoice Reference #: XAIJA-M9C62C

Event & Product Event Type : PATIENT PROGRAM Event Date : 7-Mar-16
information
Event Name : LS GRD PKK Location : GEDUNG PKK

Event ID : XAIJA-M9C62C

Product 1 : GARDASIL Split % 100%

Please fill in the Product 2 : Split %

product using drop
down list
Product 3 : Split %
Note : If SAP Cost Center
"#N/A" Finance will reject the
requested Product 4 : Split %

Product 5 : Split %

Total split% 100%

(Total should be 100%)

Payment Description: PATIENT PROGRAM LS GRD PKK

Payment Details After WHT

Type of payments Amount IDRs
SPEAKER FEE 2,061,856
Please fill in the payment
using drop down list
Note : If SAP GL Account "#N/A"
Finance will reject the requested
 Please fill in the payment
using drop down list
Note : If SAP GL Account "#N/A"
Finance will reject the requested

Total Amount : 2,061,856

Requestor Request Date : 23-Jul-20

information
Requestor Name : Agnes KH Wardhani

Requestor Email ID : agnes.kusuma.herna.wardhani@merck.com

Requestor Signature :
 Effective Jul 22nd, 2015

T REQUEST FORM
due to third parties where no Purchase Order is issued)

dor No is not found in the Vendor List, please Fill in Vendor Request Form and send to Finance.

IDR

7-Mar-16 (DD/MM/YYYY)

GEDUNG PKK

100% SAP Cost Center J20000MHPV

SAP Cost Center #N/A

SAP Cost Center #N/A

SAP Cost Center #N/A

SAP Cost Center #N/A

100%

Before WHT
Amount IDRs Reference Key 3: SAP GL Account
2,000,000 AEGA-76WSQE #N/A
#N/A #N/A
#N/A #N/A
#N/A #N/A
AIJA-HR9PO0
 Version 1.0 release date 10th Dec 2012

Effective Jul 22nd, 2015

NEW PAYMENT REQUEST FORM

(For Payment Associated with Promotional Activities due to third parties where no Purchase Order is issued)

General Company Code : 6700 PT MSD Indonesia

Information
Vendor No : 5004239
Note : If Vendor No is not found in the Vendor List, please Fill in Vendor Request Form and send to Finance.
Vendor Name : DR. MAYA SRI KAMAROEKMI

Invoice Date : 5/28/2016 (DD/MM/YYYY) Currency : IDR

Invoice Reference #: XAIJA-NSRXS9

Event & Product Event Type : RTD Event Date : 6-Mar-16 (DD/MM/YYYY)
information
Event Name : RTD GRD AYAHBUNDA Location : KLINIK AYAHBUNDA

Event ID : XAIJA-M4PYFT

Product 1 : GARDASIL Split % 100% SAP Cost Center J20000MHPV

Please fill in the Product 2 : Split % SAP Cost Center #N/A

product using drop
down list
Product 3 : Split % SAP Cost Center #N/A
Note : If SAP Cost Center
"#N/A" Finance will reject the
requested Product 4 : Split % SAP Cost Center #N/A

Product 5 : Split % SAP Cost Center #N/A

Total split% 100%

(Total should be 100%)

Payment Description: RTD RTD GRD AYAHBUNDA

Payment Details After WHT Before WHT

Type of payments Amount IDRs Amount IDRs Reference Key 3: SAP GL Account

SPEAKER FEE 2,577,320 2,500,000 AEGA-7VF55U #N/A

Please fill in the payment
using drop down list #N/A #N/A
Note : If SAP GL Account "#N/A" #N/A #N/A
Finance will reject the requested
#N/A #N/A

Total Amount : 2,577,320

Requestor Request Date : 23-Jul-20

information
Requestor Name : Luqman Hakim

Requestor Email ID : luqman.hakim@merck.com

Requestor Signature :
 Version 1.0 release date 10th Dec 2012

Effective Jul 22nd, 2015

NEW PAYMENT REQUEST FORM

(For Payment Associated with Promotional Activities due to third parties where no Purchase Order is issued)

General Company Code : 6700 PT MSD Indonesia

Information
Vendor No : 5005036
Note : If Vendor No is not found in the Vendor List, please Fill in Vendor Request Form and send to Finance.
Vendor Name : LIEM GUNAWAN CHANDRA

Invoice Date : 8/20/2016 (DD/MM/YYYY) Currency : IDR

Invoice Reference #: XAIJA-PH5M49

Event & Product Event Type : LAYMEN SYMPOSIUM Event Date : 20-Aug-16 (DD/MM/YYYY)
information
Event Name : LS GRD JAC SCHOOL Location : JAC SCHOOL SURABAYA

Event ID : XAIJA-PH5M49

Product 1 : GARDASIL Split % 100% SAP Cost Center J20000MHPV

Please fill in the Product 2 : Split % SAP Cost Center #N/A

product using drop
down list
Product 3 : Split % SAP Cost Center #N/A
Note : If SAP Cost Center
"#N/A" Finance will reject the
requested Product 4 : Split % SAP Cost Center #N/A

Product 5 : Split % SAP Cost Center #N/A

Total split% 100%

(Total should be 100%)

Payment Description: LAYMEN SYMPOSIUM LS GRD JAC SCHOOL

Payment Details After WHT Before WHT

Type of payments Amount IDRs Amount IDRs Reference Key 3: SAP GL Account

SPEAKER FEE 2,061,856 2,000,000 AIJA-PH6QWA #N/A

Please fill in the payment
using drop down list #N/A #N/A
Note : If SAP GL Account "#N/A" #N/A #N/A
Finance will reject the requested
#N/A #N/A

Total Amount : 2,061,856

Requestor Request Date : 23-Jul-20

information
Requestor Name : Luqman Hakim

Requestor Email ID : luqman.hakim@merck.com

Requestor Signature :