1

WHO Country Office, United House (Ground to 3rd Floor),

10 Gulshan Avenue, Gulshan-1, Dhaka-1212, Bangladesh.

GPN Ext.: 27220 | PABX Number: +880 96040 27200, +880 2 883

Vendor Registration Formfor Service Suppliers/Vendors and Individual Providers, WHO Bangladesh

The requested information is for WHO internal use only and will be treated as confidential.

All pages are to be completed by vendors and submitted to WHO:

Registration is open to Individual Service Providers and Vendors defined as Companies/Firms, Institutions, Profit and Non-Profit Organizations(NGOs) who are capable of delivering high quality technical services related to Health in Bangladesh.

Individual Providers and Vendors are requested to carefully read and follow the Guidance Note on Expression of Interest (IOE), which is providing information/instruction how to complete the Registration Form. They need to attach documentation as detailed out in the Registration Form.

Only written communication will be accepted for registration purposes. Verbal communication will not be addressed. All queries should be addressed in writing to the address above.

WHO is acting in good faith by issuing this Vendor Registration Form. However, this document does not oblige WHO to contract any respondents for performance of any work, nor for supply of any products or services.

(Please type or print)

Part-1:Information and Documentations

Section 1 & 2: General Information

1.Name of the Company/NGO/Organization/Individual Service Provider: ______

1.2 Year of establishment: ______

1.3 Full Address:

House:______Road: ______

City: ______Post Code:______Country: ______

Telephone: ______Fax: ______E-mail: ______

Website: ______

Name of The Chief Operating Officer/Managing Director/Head of Company/Proprietor/Executive Director: ______Designation______

Cell Numbers : ______E-mail: ______

2.a:Status of the Vendor for Services: Company Service provider Individual Service Provider

2.b:Describe the Area of Works (Technical/Programme Area): i. ______

ii. ______iii. ______

iv. ______v. ______

2.c Area of Expertise: (under Categories of Major Service) i. ______

ii. ______iii.______

2d. Legal Structure of company: NGO Limited Company: Public Limited Company:

Section 3: LegalStatus of the Vendor:

a. / Trade License: / Valid till: / Attach copy of documents
b. / Certificate of Incorporation (for Limited Companies) / Valid till: / Attach copy of documents
or / Registration of NGO Affairs Bureau h/Social Welfare Department of Government of People’s Republic of Bangladesh / Valid Till / Attach copy of documents
c. / Tax Identification (TIN): / Valid till: / Attach copy of documents
d. / Value Added Tax Registration (VAT): / Valid till: / Attach copy of documents
e. / Import Registration Certificate: / Valid till: / Attach copy of documents
h. / Bank Information: Vendor bank, account number and address
i. / Sole/Exclusive rights/license for the services (if applicable)

Section 4: Experience

Type / Brief Descriptions / Supporting Documents
Relevant Expertise/Specialization of the Services/Works, those are parts of your organization and can be linked to any of technical area for the WHO Programmes / - Provide Work Profile/Project proposals, Concepts Notes on yourExpertise/Specializationrelated to WHO’s intended technical services implemented/being implemented (shared with NGO Affairs Bureau or other Controlling Authorities/Donors)
- Reports of Activities/Projects/Assignments related to WHO’s intended technical services/works with independent reviewer’s feedback (if any) as agreed by NGO Affairs Bureau or other Controlling Authorities/Donors)
Projects/Assignments/Contracts relevant to WHO’s intended technical services/works performed/delivered with UN Agencies/Donors, Development Partners/ Public and Private Sectors, during last 5 years / Complete the Table 4 A and Table 4 Bin support of the contracts performed / Provide Agreements/Contracts/Purchase Orders/MoU

Table 4-A: List of UN System or Donor Agencies the supplier did business during last 24 months:

Names of UN System or Donor Agencies / Contact & Telephone No: / Short Description/ Activities/of the Service provided / Contract/Order No. and date / Total Sales:
(in BDT)

Table 4-B: List of other Customers/Clients (Public/Corporate sectors) during last18 months:

Names of Customer/Clients / Contact & Telephone No: / Short Description/ Activities/of the Service provided / Contract/Order No. and date / Total Sales:
(in BDT)

Section 5: Organizational capacity-Resources:

Type / Descriptions / Supporting Documents
No. of Technical Staff (Medical Professionals/Health Experts/Consultants/Project Managers/Engineers/Designers/Programmers etc.) relevant to applicant business type: / Attach Organogram (not applicable for small vendors/retailers)
Number of Management staff
Noof Sale/Marketing/Field staff
No of Operational (Administration/Finance) staff
ISO Certification/other accreditation: / Attach certificates
FDA/GMP/CE other relevant Quality Control Certificate: / Attach certificates
Necessary ICT infrastructure is maintained to operate their activities/business / Attach ICT policy/ strategy document /List of
Partnership/Joint Venture and or Affiliation with any Overseas Institutes/Organizations/Companies / Attach relevant agreement/certification
Membership or professional Network with any national and international professional bodies/Trader-commerce Federations etc. / Attach membership certificate
Any recognition of the Organization/Company/Firm for delivering outstanding performance achievement or social contribution to their works / Attach document

Section 6: Organizational capacity-Financial:

Type / Descriptions / Supporting Documents
Average Annual Turn Over the Organization/Company/Firm during of Last 2 years (not applicable for NGOs, Non profit Organizations) / Yearly turnover reported,audited/unedited financial statement /yearly Bank statements of last 2years supported by bank statements
Last 2 years Statement of Accounts of the Organization / Audited/Unaudited asaccepted by the Controlling Bodies (Bangladesh Securities and Exchange Commission, NGO Affairs Bureau/ Social Welfare Department etc.)
Credit facilities from a bank to complete contracts / Attach up to date bank certificate on the credit facilities
Financial Strength of NGOs/Organization which does not have credit facility to a bank / Yes/No / If yes, please describe how and up to which value your Organization is capable to implement a project at own resources at this moment
Last 2 years Programme Budget with Action Planof the NGO/Non-Profit Organization, Other Profitable Firms/Organization / Last 2 years Programme Budget with Action Plan approved by NGO Bureau/Social Welfare Department (as applicable)
Real Estates/Properties won/leased by the Organization to operate their activities/business / Attach audited/unaudited list of CapitalizedAssets with value
Fixed Assets won/leased by the Organization to operate their activities/business / Attach audited/unaudited list of Major Fixed Assets(total number of vehicle/Machines, etc with value.)
Request for Third Party Liability Insurance (Non-Individuals) / Attach Insurance Certificate (if any)

Section 7:Best Business Practices:

Type / Descriptions / Supporting Documents
Policy/Profile of the Organization / Document/Policy to attach
Internal Quality Control Mechanism (describe process how your Organization/Company/Firm ensure quality of services) / Supplier’s separate statement is attached
Quality Control Mechanism (does the vendor has mechanism to deliver to ensure quality:_____
Policy on Environment / Document/Policy to attach
Any of the staff/shareholders of the company is related to any staff member /contract holder of WHO
Yes No / If yes, please provide the details of staff member /contract holder with type of relation
Part-2: Declarations Statement of the Vendors

Declarations of the Vendors

1. Our Work-place is tobacco Free:

Yes No

2. We don't employ any Child Labor:

Yes No

3. Our Organization/Company/Firm enforces “No Discrimination in employment” policy:

Yes No

4. Our Organization/Company/Firm has never been involved in proscribed practices including but not limited to corruption, fraud, coercion, collusion, obstruction and any other unethical behavior, which has resulted in Lawsuit or investigation.

Yes No

5. Our Organization/Company/Firm is not currently removed, invalidated or suspended by any of the offices of UN Agencies/World Bank locally/globally.

Yes No

6. Our Organization/Company/Firm has no outstanding bankruptcy, judgment or pending legal action that could hamper our activities and operation of the business.

Yes No

7. Our Organization/Company/Firm is interested to do business with WHO as per WHO general terms and conditions including 30 days payment terms, a copy of which is provided to me.

8. Our Organization/Company/Firm confirms that we have read, understood and will comply with the WHO policy that strictly prohibits the acceptance of any type of gift and/or hospitality by UN staff members participating in the procurement process.

Yes No

9. Our Organization/Company/Firm confirms that neither we (Organization/Company/Firm), nor any of our affiliates, nor any subsidiaries controlled by the ourOrganization/Company/Firm, is engaged in the sale of manufacture of anti-personnel mines and Tobaco or of components utilized in the manufacturers of anti-personnel mines and Tabaco. The vendor recognizes that a breach of this will entitle WHO to terminate its any possible contract with the vendor.

10. Any breach of the above the declarations may lead to the termination of all contracts your Company may have with WHO and removal from the approved vendor list.

I , representing the Company or as any Individual Service Provider , acknowledge and ensure the Company’s compliance with the above statements:

Name and Title:……………………………………………………………………….

Name of Company:……………………………………………………………………

Signature:……………………………………………………………………………….

Date:……………………………………………………………………………………..