Appendix
1. Application for Registration
2. Letter of Application for Bidding
3. Tax evasion pledge
4. Manufacturer’s Authorization
5. Letter of Technical Support
6. Curriculum Vitae
7. Certificate of Employment
8. Specification of Equipment <Refer to MS Excel Document>
9. List of Documents to be Submitted(SEALED ENVELOPE)
9-1. Application for Eligibility Examination
9-2. Self-evaluation for Eligibility Examination and Examination Table
9-3. Detailed Scores by Item
10. Bid Price Proposal <Refer to MS Excel Document> (SEALED ENVELOPE)
11. Building Layout <Refer to PDF Document>
12. Financial Accounting Report
13. Supply of Goods Plan (For Successful Bidder)
[Appendix 1 Application for Registration]
Application for RegistrationTo: President of KOICA / KOICA Reg. No.
Name of Firm / Taxpayer ID No.
Name of
CEO / ID No. of
Chief Executive
E-mail / Homepage
Address of Firm / Tel. No.
Fax No.
Type of Firm / Private Firm/
Corporation / Country in which Firm is registered / Date of
Incorporation
Capital of Firm / Number of
Employees
Sales Records for past 3 years
Persons authorized
to sign Bids &
Contracts / Job Title / Name / Signature or Seal
Products
to be offered / Products / Classification Code / Sales Records
for past 3 years
Required
Documents / ◦ Certificate of Taxpayer`s ID No. or Office Ownership
I, as a legally authorized representative of the Firm, duly state that all of the above information is true and correct and hereby duly apply for registration.
※1. Documents to be submitted must be issued or authenticated by Government Agency or authority concerned of the Applicant`s country, otherwise these documents must be certified by the notary public.
2. This application form must be filled out in English. When the original documents are in a language other than English, they must be accompanied by a duly notarized English translation.
Name of CEO
/ Date
Signature or Seal
Name & Title of Applicant
E-mail :
[Appendix 2 Letter of Application for Bidding]
Letter of Application for Bidding
1. Bidding and Bid Security
Bid Title / Provision of Medical Equipment for National Pediatric Hospital in Phnom Penh, CambodiaInvitation No. / KOICA 2016-0000 / Date of Submission of bidding
documents and bid price / July,25th, 2016
Application for Bidding / (Name of Company) alone
Bid Security / UD $
※A bid security of five percent (5%) of your bid amount
(Period: at least 30 days from date of submission of bidding
documents and bid price )
2. Details of the Bidder
Section / Name of Firm / Address / Chief Executive / Bidding AgentName / Taxpayer ID No.
Representative Company / (Seal) / Name / (Seal)
We apply for participating in the above Bid in accordance with Bid Documents including Bid Instructions under International Guideline and Instructions on the International Bidding for Equipment Provision
If the successful bidder fails to enter into the contract within the prescribed period of time, the bid security deposited by the bidder shall belong to KOICA.
Attachment 1. Bid Security 1 copy
2. bidding documents and bid price, etc. 1 copy respectively
Company Name:
Chief Executive: (Seal)
Date :
Bid Security
Invitation No : KOICA-2016-0000
Project Works : Provision of Medical Equipment for National Pediatric Hospital in Phnom Penh, Cambodia
Date of Bid:
We, the undersigned, hereby guarantee that, if awarded a contract, we will perform faithfully the requirements of the contract.
(i) Should we withdraw our bid before its expiration and/or after being awarded by the Korea International Cooperation Agency (KOICA), or
(ii) Should we refuse to conclude the contract, or
(iii) Should we fail to establish a Contract Deposit in accordance with the contractual conditions,
We undertake to pay KOICA immediately an amount equivalent to five (5) percent of the total bid price, according to, and upon receipt of, its first written demand, without KOICA having to substantiate its demand.
We further guarantee that we will not claim against or appeal to KOICA in relation to any unfavorable action which may be taken against us by KOICA on the grounds that we have not complied with the above conditions.
Signed on , 20yy
Contractor:
by [ Signature ]
Name:
Title:
Guarantor:
by [ Signature ]
Name:
Title:
* A different form of security is acceptable to KOICA only when it is substantially equivalent to the form and substance of the security established by KOICA herein.
[Appendix 3 Tax evasion pledge]
Tax evasion pledge
1. We undertake full understanding and compliance of “Article 27-5 of ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY” and “Article 12 of the ENFORCEMENT DECREE OF THE ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY“. We declare that neither we nor any other party acting on our behalf with regard to the Project has engaged or will engage in corrupt or fraudulent practices.
<Reference: Article 27-5 of ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY>(Article 27-5) Restriction, etc. on Qualification for Participation of Inappropriate Business Entities in Tendering Procedures
A person for whom there is a request by the Fair Trade Commission to restrict the qualification of participating tendering, due to the violation of the Monopoly Regulation and Fair Trade Act or the Fair Transactions in Subcontracting Ac
<Reference: Article 12 of ENFORCEMENT DECREE OF THE ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY>
(Article 12) Qualifications for Participation in Competitive Tendering Procedures
A person for whom there is a request by the Fair Trade Commission to restrict the qualification of participating tendering, due to the violation of the Monopoly Regulation and Fair Trade Act or the Fair Transactions in Subcontracting Act.
2According to the above, we have to submit evidence in accordance with Article 2 (5) of the ACT ON THE LAPSE OF CRIMINAL SENTENCES, however difficult it may be to do so. We hereby confirm the following are not applicable.
PUNISHMENT OF TAX EVADERS ACTArticle 3 (Tax Evasion): A person who evades a tax of at least 500 million won.
CUSTOMS ACT
Article 270 (Offense, etc. of Evading Customs Duties): A person who has his/her custom duties imposed on personal goods that are reduced or exempted by any illegal means or that evades the collection of customs duties on goods for which customs duties have been reduced or exempted at least 500 million won.
FRAMEWORK ACT ON LOCAL TAXES
Article 129 (Evasion of Local Taxes): Any person who evades a local tax or obtains a refund or deduction thereof by deceit or other fraudulent means by at least 500 million won.
ADJUSTMENT OF INTERNATIONAL TAXES ACT
Article 34-2 (Penalty Provisions Applicable to Non-Fulfillment of Obligation to Report on Overseas Financial Accounts): Where a person is liable to report on information on his/her overseas financial account under Article 34 (1) fails to report within the reporting deadline, or under-reports the amount (hereafter referred to as "amount in violation of the liability to report" in this Chapter) exceeds five billion won.
FOREIGN EXCHANGE TRANSACTIONS ACT
Article 18 (Reporting, etc. on Capital Transactions): Any person who intends to perform capital transactions, and
Article 29 (Penalty Provisions): Any person whose amount from a violation of an obligation to report under Articles 16 or 18 has exceeded the amount prescribed by Presidential Decree within the extent of not less than five hundred million won
If the above statement is different from the fact, we confirm that we could receive sanction disposition as improper business in accordance with Article 76 of the "ENFORCEMENT DECREE OF THE ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY" and the termination of contract
Date:
Name: (sign)
[Appendix 4 Manufacturer’s Authorization]
Manufacturer’s Authorization
[The Bidder shall require the Manufacturer to fill in this Form in accordance with the instructions indicated. This letter of authorization should be on the letterhead of the Manufacturer and should be signed by a person with the proper authority to sign documents that are binding on the Manufacturer]
Date: [insert date (as day, month and year) of Bid Submission]
To: [insert complete name of Purchaser]
WHEREAS
We [insert complete name of Manufacturer], who are official manufacturers of [insert type of goods manufactured], having factories at [insert full address of Manufacturer’s factories], do hereby authorize [insert complete name of Bidder] to submit a bid the purpose of which is to provide the following Goods, manufactured by us [insert name and or brief description of the Goods], and to subsequently negotiate and sign the Contract.
We hereby extend our full guarantee and warranty in accordance with Clause 18 of the General Conditions of Contract, with respect to the Goods offered by the above firm.
Signed: [insert signature(s) of authorized representative(s) of the Manufacturer]
Name: [insert complete name(s) of authorized representative(s) of the Manufacturer]
Title: [insert title]
Duly authorized to sign this Authorization on behalf of: [insert complete name of Bidder]
Dated on day of , [insert date of signing]
[Appendix 5 Letter of Technical Support]
Letter of Technical Support
To: President of Korea International Cooperation Agency.
Project: Provision of Medical Equipment for National Pediatric Hospital in Phnom Penh, Cambodia
We hereby commit that we, the company, will designate at least three(3) qualified staffs in project site(National Pediatric Hospital in Phnom Penh, Cambodia) for technical support such as quickly the demand of repair and replacement of the goods during the deflect repair period(for 2 years)
20 . . .
Address :
Company:
Representatives: (Seal)
[Appendix 6 Curriculum Vitae]
Curriculum Vitae
Full Name
Address:
Telephone: (Mobile) Email:
LANGAUGE SKILL(Sample)
▪ Khmer : Native
▪ English : Good
EDUCATION AND TRAINING (Sample)
▪ 1999:Certificate of high school
▪ 2004:Bachelor degree of Business Administration at National University of Management (NUM) in major Management information system(MIS)
- Business English, Principle of Accounting, Principle of publish relation, Principle of management and Principle of communication.
- E-commerce, Computer system, A+ Certificate, Computer Literacy, Troubleshooting, Word Processing, Adobe Pagemaker6.5, Auto CAD R14, math in Computer, HTML, JAVA Script
▪ 2008: Certificate of GE Healthcare (Life support )Engstrom Ventilator machine for service training at Cambodia
▪ 2009: Certificate of GE Healthcare (Life support )Engstrom Ventilator machine for service training at Philippine
▪ 2011: Certificate of Effective Communication skill
▪ 2012: Certificate of GE Healthcare (Life support ) Anesthesia machine for service training at Malaysia.
EXPERIENCE (Sample)
▪ 2006: A Computer shop in major service, repair and maintenance
▪ 2008- 2016: A Medical Group Ltd in major service engineer
REFERENCE (Sample)
▪ Mr. ABC
- Officer at Ministry of Health
- Tel: 855 12345687
- Email:
[Appendix 7] Certificate of Employment
Certificate of Employment
Date :[insert date (as day, month and year) of Bid Submission]
Name : [insert Full Name]
Sex : [insert Sex]
Date of Birth : [insert date (as day, month and year) of birth]
To Whom It May Concern.
This is to certify that [Insert Full Name] has been serving as a [Insert the Title] at [Insert complete name of company] since [Insert date (as day, month and year) of employment]
Sincerely Yours.
Signed: [insert signature(s) of authorized representative(s) of the company]
Name: [insert complete name(s) of authorized representative(s) of the company]
Title: [insert title]
[Appendix 8] Specification of Equipment
Refer to MS Excel Document
[Appendix 9] List of Documents to be Submitted
List of Documents to be Submitted
(Those Documents (Appendix 9-1~3) should be sealed with Price Proposal)
Examination Area / Serial No. / Contents / Issuing Institution(Certifying Institution) / Remarks
General / 1
2
3 / Application for eligibility examination
Self-evaluation for eligibility
examination and examination table
Detailed scores by item / Applicant
-〃-
-〃- / Attached Form 11-1
Attached Form 11-2
Attached Form 11-3
[Appendix 9-1] Application for Eligibility Examination (SEALED ENVELOPE)
(Attached Form 1)
Application for Eligibility Examination
ㅇPublic Notice No.:
ㅇName of Tender:
ㅇDate of Tender:
I hereby submit the self-evaluation for eligibility examination and examination table and other evidential documents, prepared in good faith, for eligibility examination relating to the above tender to manufacture or purchase goods, and if it is confirmed that any of the documents submitted has been prepared by fraud or other wrongful means, I hereby pledge not to raise any objections to handling of this case in accordance with the Eligibility Examination Criteria of the Korea International Cooperation Agency, the Regulations on Contracts and Procurement relating to Foreign Grant Aid and Cooperation Programs, the Detailed Regulations of the same Regulations, and the Act on Contracts to which the State is a Party.Date Month Year
Bidder subject to Examination Address:
Company Name:
Representative: (Seal)
Attachments:
1. One copy of the self-evaluation for eligibility examination and examination table;
2. One copy of the detailed scores by item;
3. One copy of a certificate of delivery (sales) performance of goods, or a confirmation of delivery (sales) performance of goods (limited to manufacture of goods);
4. One copy of a confirmation of credit ratings; and
5. Other accompanying documents (evidential materials for evaluation of credibility, etc.)
To the President of the Korea International Cooperation Agency
[Appendix 9-2] Self-evaluation for Eligibility Examination and Examination Table (SEALED ENVELOPE)
(Attached Form 2)
Self-evaluation for Eligibility Examination and Examination Table
1. Goods subject to examination 2. Bidder subject to examination
Public notice No. for tender / Company name / (Tel.)Representative
Date of tender
Business type / Manufacturing( ),
Supply( ), Others ( )
Product name
3. Personal information on the person in charge of contact on behalf of the company
Quantity
Department in charge
Position
Bidding price
Name
Estimated price
Contact number / (Fax)
4. Comprehensive evaluation
(Unit: point)
Category / Limits on point allocation / Self-
evaluation score / Examination score
Total / 100
Management status / 30
Tender price / 70
Credibility / 1
Grounds for disqualification / -30
[Appendix 9-3] Detailed Scores by Item (SEALED ENVELOPE)
(Attached Form 3)
Detailed Scores by Item
Total score / ( ) pointsType of business subject to evaluation
Ⅰ. Management status: ( ) points
ㅇManagement status shall be evaluated according to "evaluation method by credit ratings,“ and the detailed evaluation method applied shall be specified in attached Table 1-3.
Ⅱ. Tender price: ( ) points
Tender price (a) / Projected price (b) / Calculation: 70-2x│(88/100-a/b)x100│ / Score※If a tender price below the projected price is at least 95.5/100 of the projected price, then the score shall be 55 points.
※The lowest score shall be 2 points.
※However, an evaluation of the tender price shall be prepared by the Procurement and Contract Team.
Ⅲ. Credibility: ( ) points
Examination Item / Evaluation Factor / Limits on Point Allocation / Details of Grade / ScoreLevel of reliability of quality control, etc. / Technology certification, etc. / + 3 points
Level of conscientious fulfillment of contracts / Delayed delivery, etc. / - 2 points
[Appendix 10] Bid Price Proposal (SEALED ENVELOPE)
Refer to MS Excel Document
For Bid Price Proposal and detailed price statements in MS Excel Document, paper and CD must be submitted in sealed envelope
[Appendix 11] Building layout
Refer to PDF document
[Appendix 12] FINANCIAL ACCOUNTING REPORTS IN RECENT YEAR (2015)
DESCRIPTION / 2015 / RemarkTotal assets
Total sale
Equity capital
Current Liabilities
Fixed Liabilities
Current assets
Net profit
Cost of sales
Net profit to net worth ratio / Net profit/Equity capital
Debt ratio / Total liabilities/Equity capital
Liquidities ratio / Current assets/Current liabilities
Equity ratio / Equity capital/Total capital
※Notice
○ 01 Copy of latest Statement of Account (Balance sheet, Statement of profit and loss) should be attached.
○ All certificates and confirmations must be submitted after the date of announcement.
- In case of no alteration, all submitted documents must be certified copies.
[Appendix 13] Supply of Goods Plan (For Successful Bidder)
Supply of Goods Plan
( Name of Project )
DD/MM/YYYY
Name of Company :
1. General Information (Details of supplies and procurement method)
※Replaced by the specification (MS Excel form) of Appendix 8.
- Every entry must be filled out completely in Excel and no modifications are allowed.
□ Notes
○ Persons participating in an inspection must be a contractor. If manufacturer representative participates, the responsibility to comply with the contract remains with the contracting party. Otherwise, it shall be regarded as an unfair inspection and shall be warned in accordance with the relevant regulations.
○ The details of the goods (MS Excel) are confirmed to be equal to or more than the specifications in the work instruction manual. If the items of delivery are changed without prior approval from KOICA, the details will not be acknowledged regardless of the reason.
- Documents such as the quality assurance certificate for equipment, strategic materials, shipping reference documents, etc. must be provided before the inspection date. Manuals, such as the manual accompanying the equipment, can be adjusted before the inspection.
- The schedule of the supply plan should follow the delivery deadline on RFP, and must be able to supply items that can meet the delivery deadline (To determine timely timelines for procurement).
※Items that have abnormal qualities (items that do not meet essential requirements / relevant law permits) may be rejected, even if they submit quality assurance as ready-made products.
* In the case of local purchases, the relevant tax is determined according to the tax law of the country in question, Which takes this into consideration and keeping the bid in mind. (Refer to the bid announcement)
2. Maintenance and Quality guarantee
* The duration of maintenance and warranty is the same as the contract conditions.
3. Supply Schedule
○ Schedule may be adjusted after notification to, and approval of, KOICA. Evaluated upon individual circumstances, KOICA may not approve excluding terms of a contract and schedule change.
- Any person responsible for supply schedule changes or delays that are not approved by KOICA will be warned.
Contents of Work / schedule / NoteDate to submit Strategic material judgment / Within 00 days from the contract date / Within 1 month before delivery date(When you change the item, it will be submitted after inspection)
Domestic delivery (inspection application)
due date / Within 00 days from the contract date / The inspection period is up to 7 days.
Inspection schedules are planned in consultation with the supplier
Notification of Inspection / Notify 2 weeks before delivery date
Submit documents related to delivery / Within 7 days before delivery date / In accordance with RFP
Delivery deadline (Domestic) / Within 00 days from the contract date
* notify of delivery delay / Included in the warning of non-papers
Shipping Documents (Delivery List)
Date to submit / Immediately after delivery
* notify of shipment delay / Send KOICA and logistics companies
Submission of the dispatch plan
(Local installation, etc.) / Within 7 days from the request date of KOICA / Check the Customs due date
Discuss on the Contents of dispatch
Departure date / Within 7 days from the request date of KOICA
* notify of departure delay / If there is an unavoidable reason, submit a statement of reasons
Start local installation
(Including local purchase) / If there is not an unavoidable reason at the time of arrival, recommendation of local purchase and installation / When preparing the dispatch plan, submit date and details
(Within DD/MM/YY)
Local installation and
Inspection application date / Within 30 days from arrival (customs clearance day)
* notify of delivery delay / When preparing the dispatch plan, submit date and details
(Within DD/MM/YY)
Maintenance plan / Billing after completion of local installation / Payment will be made after reviewing the contents
4. Person in charge of Project (At least one person from the contractor)