EXXONMOBIL UPSTREAM NIGERIA AFFILIATES
(MPNU/ESSO COMPANIES)
Supplier’s Registration Form
Company and Business Profile
Name of Company: / D-U-N-S® Number (See below) :Website: Telephone: Fax:
Registered Office Address:
Principal Owners or Partners / Name: / Name: / Name:
LGA: / LGA: / LGA:
Nigerian Reg. Data: SelectCompanies DecreeBusiness Name Reg Act / Reg. Number: / Date: dd-mm-yyyy
If Registered under Companies Decree, State if Limited Liability Company:
Is Your Company affected by the Nigerian Enterprises Promotion No. 4 of 1972:
State Paid Up Capital: State Turnover for the last 12 months:
State Equity Participation of Nigerian Citizens or Associations in your company:
State Type of Service(s) Offered or List and attach to Application: Select Advertise & PromoteChemical/Gas/UtilityConstruction ServiceDrilling MaterialsDrilling ServicesElectrical EquipmentExploration ServicesInformation Systems Instrument/ControlsIntegrated LogisticsMedical/Fire/Safety Mining EquipmentOffshore ServicesPiping CommoditiesRotating EquipmentStatic EquipmentTelecommunicationsToolsTransport EquipmentTransport ServicesPetroleum Products & LubesWarehouse & PackageWell Completion Materials Well Completion Services / How long have you been in this type of business/service(s)? Years
Are you willing to post a 10% Cash Performance Bond for any contract you undertake?
Directorship (Please states names of Company Directors and their Nationality)
Names (Please print in capital letters) / Nationality / Names (Please print in capital letters) / Nationality
1. / 2.
3. / 4.
5. / 6.
Work Performance History (Please provide details of similar service(s) performed in the past for reputable clients)
Client / Execution Date / Location / Total Value of Contract / Client contact person
1. / dd-mm-yyyy
2. / dd-mm-yyyy
3. / dd-mm-yyyy
4. / dd-mm-yyyy
5. / dd-mm-yyyy
Do you have any objection to our discussing your performance with the persons listed above?
If yes, please state reason:
Banking Details (Please provide details of your company bank accounts)
Bank Name / Location / Account Type / Account Number / Remarks
1.
2.
3.
APPLICANT’S SIGNATURE:
TITLE:
DATE: dd-mm-yyyy
APPENDIX “A”
CONTRACTOR SAFETY DATA REQUEST
Company Name:Address:
City: / State:
Country: / Tel: / Fax:
Safety Contact: / Phone:
Select The Type Of Work Your Company Performs: Select Advertise & PromoteChemical/Gas/UtilityConstruction ServiceDrilling MaterialsDrilling ServicesElectrical EquipmentExploration ServicesInformation Systems Instrument/ControlsIntegrated LogisticsMedical/Fire/Safety Mining EquipmentOffshore ServicesPiping CommoditiesRotating EquipmentStatic EquipmentTelecommunicationsToolsTransport EquipmentTransport ServicesWell Completion Svces Well Completion Matls Petroleum Products & LubesWarehouse & Package
Prepared By: / Date: dd-mm-yyyy
CHECK ONLY ONE
1. Does your company have a written policy statement?
2. Does your company provide a written safety manual for each of its employees?
3. Does your company have documented emergency response procedure?
4. Does your company have employee safety rules with disciplinary action established?
5. Does your company have regularly scheduled (formal) safety meetings and record available for inspection?
6. Does your company have established safety training program?
7. Does your company have safety inspection program?
8. Does your company have a safety professional on staff?
9. Does your company have an alcohol/drug control policy?
10. List the personal protective equipment (PPE) provided to your employees:
1. / 2. / 3.4. / 5. / 6.
11. Does your company have a safety awareness/incentive program for its employee?
IF YES PLEASE DESCRIBE:
12. Please provide the following information concerning the training you provide for your employees:
TRAINING / FREQUENCY / TRAINER / ANY RECORDS? /FIRST AID / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
CPR / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
HAZARD COMM / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
LOCKOUT/TAGOUT / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
ELECTRICAL SAFETY / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
EXCAVATION, SHOPPING TRENCHING SAFETY / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
CONFINED SPACE ENTRY / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
FALL PROTECTION SAFETY BELTS / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
PROPER USE OF PPE / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
HEARING CONSERVATION / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
USE/INSPECTION OF HAND HELD FIRE EXTINGUISHER / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
H2S / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
WATER SURVIVAL / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
WELL CONTROL (BOP TRAINING) / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
CRANE CERTIFICATE / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
FORK LIFT CERTIFICATE / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
SLIPS/TRIPS/FALLS / SelectBi-AnnuallyAnnuallyQuarterlyMonthlyIrregularNever / SelectYesNo /
13. What minimum safety training is provided to your employees before they can work offshore?
1. / 2.3. / 4.
5. / 6.
14. EXPERIENCE FACTORS:
a. Total number of recordable incidents this year:
b. Total number of recordable incidents last year:
c. Total number of recordable incidents in the last 2 years:
d. Total number of recordable incidents in the last 4 years:
e. Total number of lost work days in this year:
f. Total number of lost work days in the last 2 years:
g. Total number of lost work days in the last 4 years:
*** Please feel free to provide any additional information, documentation(s) or manuals that can assist us in our inquiry.
APPENDIX “B”
PROSPECTIVE BUSINESS ASSOCIATES QUESTIONNAIRE
Please provide answers to information regarding all the questions below. Please attach a separate sheet for answers requiring more space than provided in this form. Also attach all requested additional documents to this completed response.
1. Identifying Information
a. Name of Company or Individual:
b. Business Address (principal place of business and address for purposes of communications with ExxonMobil, if different from the principal place of business):
c. Telephone:
d. Fax:
e. Telex:
f. E-Mail:
2. Business Information
a. Date and place of company formation (please attach copies of formation documents):
b. Principal lines of business of company (please attach any available public reports):
c. Other locations of business:
d. Has your company or any of its principal officers, or shareholders ever been charged with a criminal offense? Yes No. If yes, provide details:
3. Ownership and Management
a. If a company, are you publicly held? Yes No. If yes, what percent?
b. If yes, please attach a copy of your most recent public filing showing the company’s shareholders, partners, or owners; if this filing does not list major (>5%) shareholders, please identify the major shareholders (public and non-public):
c. If you are not publicly held, please give the names and nationalities of all of your shareholders, partners, and beneficial owners. Please indicate the exact ownership interest of each person or company listed. (If one or more of your owners is a company, list the ultimate beneficial owner(s) and any intermediate entities or persons owning an interest in that company):
d. Give the names and nationalities of all officers, directors, managers, or other employees with executive or management authority. Please provide this information as well for any company that is the ultimate beneficial owner of your company, and of all employees who will be managing the performance of services under the proposed contract:
e. Do any of the persons listed in “c” above hold directorship or any position(s) with other companies or entities? Yes No. If yes, give the name of each company and the title of the relevant position:
f. Please list the names and addresses of any other individual, company or entity that will receive any portion of the payment (for services) as a result of participating in any type of partnership, joint venture or alliance with your company in performing the work covered by the proposed contract.
4. Relationships with Governments and Public International Organizations
Definition: “Official” means any agent, officer, or employee (elected, appointed, or career) of (1) a government or any department or agency of a government at the federal, regional or local level; (2) a political party or candidate for political office; (3) any company in which a government holds a substantial ownership interest; or (4) a public international organization such as the World Bank, the United Nations or the International Monetary Fund.
a. Are any of the persons identified in response to question 3:
i. Officials? Yes No
ii. Close relatives of Officials? Yes No
iii. Prior Officials? Yes No
iv. Involved in any business relationship, including acting as an agent or consultant for, or holding common ownership of any business enterprise or partnership with, any official or close family member of an Official? Yes No
b. If the answer to any of (i) through (iv) is yes, provide details, including:
i. full name of Official:
ii. official responsibilities:
iii. dates of service (current or past):
iv. for relatives, the relationship:
v. for common business interest, the type of business relationship, including the name of any enterprise or partnership, and the nature of any agency agreement:
Signed: Dated:
[Name and Title]:
APPENDIX “C”
REGISTRATION AND ENQUIRIES
Registration Requirements
1. A copy of your Current Permit to operate as an Oil Industry Service Company obtainable from the Department of Petroleum Resources (DPR).
2. Completed EXXONMOBIL UPSTREAM NIGERIA AFFILIATES Application for Approved Contractor Status Form N.0015.
3. Completed Safety Health and Environment (“SHE”) Questionnaire (APPENDIX ‘A’ to Form N.0015).
4. Completed Prospective Business Associate Questionnaire (“PBAQ”) (APPENDIX ‘B’ to Form N.0015).
5. A copy of your VAT Certificate of Registration.
6. A copy of current Tax Clearance Certificate from the Federal Government of Nigeria.
7. Dun and Bradstreet (D&B) D-U-N-S® Number
Submission of Registration Documents
§ EXXONMOBIL UPSTREAM NIGERIA AFFILIATES shall not process incomplete set of documents.
§ Completed forms and registration documents shall be sent online to
§ Please note that registration is not a guarantee of patronage or award of contracts by EXXONMOBIL UPSTREAM NIGERIA AFFILIATES.
Enquiries
For further clarification/enquiry on Contractor’s registration with EXXONMOBIL UPSTREAM NIGERIA AFFILIATES kindly contact:
,
09091026834.
Dun & Bradstreet (D&B) D-U-N-S® Number
The D&B D-U-N-S® Number is a unique nine-digit identifier for companies worldwide in the D&B Global database. To obtain the D&B D-U-N-S® Number or update your information with D&B, contact the local D&B Office in Nigeria;
Dun & Bradstreet Nigeria Limited
16B Allen Avenue
Ikeja, Lagos
Tel: +234 706 858 3198
Mobile: +234 903 294 0804
Email:
Note
ExxonMobil Nigeria does not accept fees or gratuities for supplier’s registration. However registration with DPR and Dun & Bradstreet may attract some charges.