Supplier Information Form استمارة معلومات المزود
Annex C – الملحق ج
Tender Ref. ADE 031
The information provided will be used to evaluate the Company before contracting with the Ghadaq.
Please complete all fields.
المعلومات المقدمة سيتم استخدامها لتقييم ر
الشكة قبل التعاقد مع منظمة غدق
ى
يرج استكمال جميع البيانات
Supplier Information معلومات المزود
Company Name
اسم ر
الشكة
Any other names company
is operating under
(Acronyms, Abbreviations,
Aliases)
( الشكة ضمنهاي اسم اخر تعمل ر
) مخترص، اختصار
Previous names of the
company
اسماء سابقة ر
للشكة
Address
العنوان
Website
موقع الشبكة العنكبوتية
Phone/Fax Numbers
Phone: Fax:
الفاكس/الهاتف
Name:
Primary Contact
Phone Number:
مسؤول التواصل
Email Address:
# of Staff
عدد العاملي
# of Locations
المكاتب او الفروع/ عدد المواقع
Avg. Value of Stock on Hand
(USD)
المال بالدوالر
ي معدل قيمة الرصيد
االمريك
ي
Government - owned
(yes/no)
رشكة مملوكة للحكومة
) ال/ (نعم
Name(s) of Board of
Directors
اسماء اعضاء مجلس االدارة
Supplier Information Form Ghadaq Employee Initial ______ 1/6
Name(s) of Company
Owner(s)
مالك ر/اسم مالك
الشكة ي
Parent companies, if any
اسم ر
الشكة االم ان وجد
Subsidiary or affiliate
companies, if any
اسماء ر
الشكات الفرعية او الشقيقة
ان وجد
Financial Information المعلومات المالية
Bank Name and Address
اسم وعنوان البنك
Name under which company
is registered at bank
اسم ر
الشكة المسجلة لدى البنك
Payment Terms Payment By: Check Yes | No Wire Transfer Yes | No
رشوط الدفع ال/ شيك نعم: عب
الدفع ر ال/ نعم: حوالة بنكية
Specify Standard Payment
Terms (Net15, 30, etc.)
حدد رشوط الدفع االساسية
Product/Service Information معلومات الخدمة
List Range of
Products/Services Offered
قائمة الخدمات المقدمة
Basis For Pricing (Catalog,
List, etc.)
انظمة التسعب
) الخ، قائمة،( كاتالوج
Supplier Information Form Ghadaq Employee Initial ______ 2/6
المراجع References
Client Name: Contact Name, Phone, Email Address:
اسم الزبون ون ،عنوانه ر
اسم المسؤول عن التواصل ،رقم هاتفه ،بريده االليكب ي
Client Name: Contact Name, Phone, Email Address:
اسم الزبون ون ،عنوانه ر
اسم المسؤول عن التواصل ،رقم هاتفه ،بريده االليكب ي
Client Name: Contact Name, Phone, Email Address:
اسم الزبون ون ،عنوانه ر
اسم المسؤول عن التواصل ،رقم هاتفه ،بريده االليكب ي
Supplier Information Form ______ Ghadaq Employee Initial 3/6
Supplier Self-Certification of Eligibility
Company certifies that:
1. It, its affiliates and subsidiaries, owners, officers, directors and key employees (to the best of its knowledge)
are not the subject of any government’s sanctions, designations, donor rules or prohibitions, or laws
prohibiting transactions with it/them. It is not the subject of any donor government investigation into its
misconduct with any other recipient of that donors funding.
2. It, its affiliates and subsidiaries, owners, officers, directors and key employees have not and do not engage
in any form of terrorism or attacks on civilians and do not provide any form of material support or financial
resources for individuals or organizations that do engage in any form of terrorism or deliberate attacks on
civilians.
3. It, its affiliates and subsidiaries, owners, officers, directors and key employees have not and do not engage
in weapons or drugs manufacture, transport, sale or distribution.
4. It is not in default on any material credit agreement, bankrupt or being wound up, are having its affairs
administered by the courts, have entered into arrangements with creditors, have suspended business
activities, are the subject of proceedings concerning those matters, or are in any analogous situation arising
from a similar procedure provided for in national legislation or regulations.
5. It is has not been determined to be in breach of a material contract by any legal body anytime within the
past 2 years.
6. It pays taxes as and when due and is not currently the subject of any investigation or proceeding related to
back-owed taxes.
7. It provides workers compensation insurance to its workers in accordance with the laws of the countries
where it operates.
8. It pays social security obligations as required in the countries where it operates.
9. It, its owners, officers and directors have not been convicted of an offense concerning its professional
conduct and has not engaged in grave professional misconduct.
10. It, its affiliates and subsidiaries, owners, officers, directors and key employees have not been the subject of
criminal investigation or judgement for fraud, corruption, human trafficking, spying, weapons transport or
smuggling, sexual exploitation or abuse, involvement in a criminal organization or any other criminal
activity.
11. It treats its employees with dignity and respect and maintains social operating standards, including::
working conditions and social rights: avoidance of child labor, bondage, forced labor, human trafficking or
exploitation; assurance of safe and reasonable working conditions; freedom of association; freedom from
exploitation, abuse, and discrimination; protection of basic social rights of its employees and Ghadaq
beneficiaries.
12. To the best of its knowledge, no Ghadaq employee, officer, consultant or other party related to Ghadaq has
a financial interest in the Company’s business activities, nor is any Ghadaq employee related to any owner,
officer, director or employee of the company, and, if so, it will ensure that the relationship is disclosed to
Ghadaq and will not use for improper influence. Discovery of an undisclosed Conflict of Interest will result
in immediate revocation of the Company’s Authorized Supplier status and disqualification of Company from
participation in future Ghadaq procurement.
13. It understands that attempting to or agreeing to provide anything of value to any Ghadaq employee, agent
or representative for the purpose of encouraging that person to award Company a contract or take or not
take any action related to any contract will result in immediate termination of any agreement. Company
certifies that it does not engage in such conduct.
14. It understands that Ghadaq seeks fair and open competition and the fairest price available and that any
attempt by company to subvert fair and open competition, including working with other bidders to fix
prices, working to exclude competition, seeking confidential information from Ghadaq or other bidders,
using multiple related or controlled companies to give the appearance of competition, or any similar
Supplier Information Form Ghadaq Employee Initial ______ 4/6
activity, will result in termination of any agreement. Company certifies that it does not engage in such
conduct.
15. It understands that Ghadaq prohibits any of its partners or suppliers from bribing public officials and
certifies that it does not do so.
16. It is not conducting business under other names or aliases that have not been declared to Ghadaq.
If the Company cannot certify to any of the above it should explain why not. Ghadaq may take the individual
circumstances into account for some situations. However, any false certification could be grounds for immediate
disqualification and termination of any future agreement.
By signing the Supplier Information Form, you certify that your Company is eligible to supply goods and services to
major donor funded organizations and that all of the above statements are accurate and factual.
Company Name:
Name of Representative:
Title:
Signature:
Date:
Supplier Information Form Ghadaq Employee Initial ______ 5/6
FOR Ghadaq USE ONLY
Following documents have been provided :
Documents
Legal Business Registration
Latest Tax Registration Certificate
Zakat Card
Technical proposal
Sample delivery plan with timeframe
Price sheet
Supplier information form
Cover Letter
Bill of Quantities
Specification form
I ________________________ an employee of Ghadaq having completed and reviewed this form confirm the
accuracy of information provided:
Name ______________________________
Title ______________________________
Signature ______________________________
Date* ______________________________
*Supplier to be re-authorized one year from this date.
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Supplier Information Form Ghadaq Employee Initial ______ 6/6
