Appendix D: SUPPLIER´S QUESTIONNAIRE

Thank you for completing this form which we ask all suppliers to do.

Publication reference: ITT14/001/DC/ECHO

Company name :

1. OXFAM INTERMON staff member you have main contact with, if any :

Name / Department / Office Location

Part A: Your Business Details

2. Please provide the address of your business including post code.

Registered Office / Ordering Address
(if different) / Payment Address
(if different)

3. Please provide your telephone, fax number, email and web site address:

Phone / Fax
Email / Web Site

4. Location of other operational sites (national and international), their functions and approximate number of employees. Attach a full list if space is insufficient.

5. Please state the nature of your business and your main products / services

6. Please provide your company registration number, years in business and VAT number:

Company Reg. No / Years in Business / VAT Number

7. What is the legal status of your business?

Public Limited Company / Partnership / Sole Trader / Private Company
Not for profit organisation / Government Agency / Self Employed
8a. Company turnover in € or local currency:
8b. Turnover of the part of the business that would serve OXFAM INTERMON:

Part B: Your Bank Details

9. Please provide your bank details, and bank account number,

Bank Name , Branch and Address: / SWIFT/BIC: / IBAN

10. Declaration (to be signed by Finance Manager)

I confirm that all the information given is accurate. For and on behalf of the supplier:
Name
Position
Date
Signature

Part C: Your Operational Standards

11a. How many people does the company employ?
11b. Approx % of women

12. Does your company have any of the following policies or statements? Please provide copies:

Quality statement / Health & Safety / Environmental Management
Equal Opportunities / Ethical / Training and Development
Social Objectives / Diversity

13. Does the company have any recognised Operational Standards for the services supplied to OXFAM INTERMON?

Quality
eg ISO9000 / Environment
eg ISO14001 / Labour
eg SA8000 / Training
eg Investors in People
Certified to :
Working towards:
Other standards:

14a. Is there anyone designated as being responsible for Health and Safety issues for your company?

Yes / No Give details

15. Please provide details of 3 customers/clients for whom you have completed contracts for in the last 3 years who are willing to provide a reference. If available, attach reference letters.

Reference 1 / Reference 2 / Reference 3
Customer/ Organisation
Contact Name
Telephone No
Date Awarded Contract
Contract scope and details
16. Please detail what experience you have with dealing with International Non Governmental Organisations (INGO): If yes, please provide details about the scope of contract and the name of the INGO.

17. If you supply services to INTERMON OXFAM, do you subcontract/outsource services?

Yes / No / NA
If YES, please state:
Type of service
Name / address / Phone and contact details of the sub-contractors

18. Declaration of duly authorised person:

I confirm that all the information given is accurate. For and on behalf of the supplier:
Name
Position
Date
Signature and
Stamp of the company