AFENET Nigeria Office NO 50 Haile Selassie Street Asokoro, Abuja Tel: +234-908 720 2044; Website: www.afenetnigeria.net PRE-QUALIFICATION REGISTRATION FORM Pre-Qualification of Suppliers, Vendors, Distributors, Manufacturers & Service Providers
The African Field Epidemiology Network (AFENET) wishes to pre-qualify all its Suppliers, Vendors, Manufacturers, Distributors, and Service Providers in order to streamline its procurement procedures. All reputable and established firms are invited to apply for the participation in the Pre-qualification Process and submit the attached Pre-Qualification forms. A transparent evaluation method for the purpose of Pre-Qualification of the applicant s capabilities in the respect of vital elements of applicant s organization and capacity to perform shall be established in order to participate in the AFENET tenders. Each Supplier or Vendor performance in terms of quality, delivery, after sales service, credit terms and other contractual obligations will be closely monitored and periodically reviewed during the contractual period. You are required to carefully read through the form and complete it accordingly. All information contained in the form should be consistent with supporting documents.
Prequalification Form Particulars Company Name Abbreviated Name Tax Registration No. No. of Employees Area of Specialization Applied for Pre- Qualification Company s Date of Formation Please attach copies of registration certificates Type of Firm (please tick one) a) Private Limited b) Sole Proprietor c) Joint Venture d) Partnership If your organization is a partnership, please provide the following information: Date of partnership: Type of partnership (if applicable) Registered Office Address: Office Telephone Number: Office Email and Website Address:
Financial Work of the Company/Supplier Company Net Worth Company Turn Over Last 3 years of Company Profits Year Profit/Loss * In case of Private Limited, please attach audited balance sheet for the last three years CEO/Chairman Name Mailing Address Phone Number Email Address Fax List of Board of Directors of Partners or Management Name Position Phone No Email 1 2 3 4 5 Company/Supplier Profile 1 Primary Business Details 2 List of Items/Services
3 List of Authorization 4 After Sale Services 5 Warranty Details 6 Buy Back or Return Policy 7 Any Other Information that the Supplier may like to Provide List of Current Customers (Companies / Organizations / Businesses) No. Name of Company Title of Contract Contract Owner Amount of Award Date of Award Completion Date 1. 2. 3. 4. 5. (Attach documentary proof with proper reference for the companies/organizations mentioned above) Additional paper may be used Technical Standing of the Firm List of Technical Personnel in Permanent Employment of the Firm No. Name Designation Years of Service Experience Responsibilities 1.
2. 3. 4. 5. CAPACITY/EXPERIENCE: PRINTING: 1. If you indicated printing as your type of business, do you have a printing press? YES NO 2. Provide the physical address of the printing press (verifiable address) 3. Has your organization failed to complete any awarded contract within the last five years? YES NO If yes, please explain 4. Would you be willing to allow us to inspect your business premises within a given notice period? YES NO
Integrity Pact/Disclosure Clause Declaration of Fees, Commissions and Brokerage Etc. Payable by the Suppliers, Vendors, Distributors, Manufacturers, Contractor & Service Providers of Goods, Services & Works: the Seller / Supplier / Contractor hereby declares its intention not to obtain the procurement of any contract, right, interest, privilege or other obligation or benefit from AFENET or any administrative sub-division thereof or any other entity owned or controlled by it through any corrupt business practice. Without limiting the generality of the forgoing the Seller / Supplier / Contractor represents and warrants that it has fully declared the brokerage, commission, fees etc., paid or payable to anyone and not given or agreed to give and shall not give or agree to give to anyone within or outside Uganda either directly or indirectly through any natural or juridical person, including it s affiliate, agent, associate, broker, consultant, director, promoter, shareholder sponsor or subsidiary, any commission, gratification, bribe, finder s fee or kickback whether described as consultation fee or otherwise, with the object of obtaining or including the procurement of a contract, right, interest, privilege or other obligation or benefit in whatsoever form, except that which has been expressly declared pursuant hereto. The Seller / Supplier / Contractor certifies that it has made and will make full disclosure of all agreements and arrangements with all persons in respect of or related to the transaction with AFENET and has not taken any action or will not take any action to circumvent the above declaration, representation or warranty. The Seller / Supplier / Contractor accepts full responsibility and strict liability for making any false declaration, not making full disclosure, misrepresenting facts or taking any action likely to defeat the purpose of this declaration, representation and warranty. It agrees that any contract, right, interest, privilege or other obligation or benefit obtained or
procured as aforesaid shall without prejudice to any other right and remedies available under any law, contract or other instrument, be voidable at the option of AFENET. Notwithstanding any rights and remedies exercised by AFENET in this regard, the Seller / Supplier / Contractor agrees to indemnify AFENET for any loss or damage incurred by it on account of any corrupt business practices. The information given above is true to the best of our knowledge. We undertake to inform AFENET of any changes that may take place later in the status of the company in business or the management. Authorized Signature: Name: Designation: Date: Note: In case of insufficient space against any column, please attach separate sheet(s) for details/information.