Tender Submission Form (Including Tenderer S Declaration)

Annex Ia

Tender submission form

Call for tender n°EAHC/2012/Health/01 concerning Multiple Framework Contracts in cascade for the "Scripting, planning, conduction and evaluation of

exercises, training and assessment implementing the draft Decision on cross-border threats to health"

Please fill in the form in English and leave the irrelevant parts blank. One signed original and 4 copies of this form must be submitted.

1.1 In case of a single tenderer

The tender is submitted by

Name of the tenderer[1]
Address
City
Postcode
Country
Website
E-mail

The contact person for this tender is

Name
Position/function
Office address
Telephone
Fax
E-mail

The person authorised to represent the tenderer and to sign the contract is

Name
Position/function
Office address
Telephone
Fax
E-mail

1.2. In case of a consortium

Please indicate the name of the consortium (if applicable), the name and the contact details of each consortium member.

Please attach:

- a signed letter of mandate from each consortium partner in original (see Annex Ib),

- if applicable, a copy of the statutes of the consortium/consortium agreement.

Name of the consortium (if applicable): ………………………………………………...

1.2.1 Consortium member 1 (Consortium leader):

Name of the consortium member[2]
Address
City
Postcode
Country
Website
E-mail

The contact person for the consortium leader is

Name
Position/function
Office address
Telephone
Fax
E-mail

The person authorised to represent the consortium leader is

Name
Position/function
Office address
Telephone
Fax
E-mail

1.2.2 Consortium member 2

Name of the consortium member[3]
Address
City
Postcode
Country
Website
E-mail

The contact person for the consortium member is

Name
Position/function
Office address
Telephone
Fax
E-mail

The person authorised to represent the consortium member is

Name
Position/function
Office address
Telephone
Fax
E-mail

1.2.3 Consortium member 3

Name of the consortium member[4]
Address
City
Postcode
Country
Website
E-mail

The contact person for the consortium member is

Name
Position/function
Office address
Telephone
Fax
E-mail

The person authorised to represent the consortium member is

Name
Position/function
Office address
Telephone
Fax
E-mail

Tenderers shall add as many sections as the number of consortium members.

1.3. In case of subcontracting

Please indicate the name and the contact details of each subcontractor already identified.

In addition, please indicate

- the approximate proportion of the contract that you intend to subcontract (i.e. in case of more subcontractors, please calculate the total of their proportion): ……%

- and the approximate proportion of the contract for each subcontractor below.

1.3.1 Subcontractor 1

Approximate proportion of the contract for subcontractor 1: ….. %

Name of the subcontractor[5]
Address
City
Postcode
Country
Website
E-mail

The contact person for the subcontractor is

Name
Position/function
Office address
Telephone
Fax
E-mail

The person authorised to represent the subcontractor is

Name
Position/function
Office address
Telephone
Fax
E-mail

1.3.2 Subcontractor 2

Approximate proportion of the contract for subcontractor 2: ….. %

Name of the subcontractor[6]
Address
City
Postcode
Country
Website
E-mail

The contact person for the subcontractor is

Name
Position/function
Office address
Telephone
Fax
E-mail

The person authorised to represent the subcontractor is

Name
Position/function
Office address
Telephone
Fax
E-mail

1.3.3 Subcontractor 3

Approximate proportion of the contract for subcontractor 3: ….. %

Name of the subcontractor[7]
Address
City
Postcode
Country
Website
E-mail

The contact person for the subcontractor is

Name
Position/function
Office address
Telephone
Fax
E-mail

The person authorised to represent the subcontractor is

Name
Position/function
Office address
Telephone
Fax
E-mail

Tenderers shall add as many sections as the number of subcontractors already identified.

2. Statement

In case of a single tenderer and/or subcontracting, only the tenderer shall sign the ‘Tender submission form’. If the tender is submitted by a consortium, the ‘Tender submission form’ shall be signed by the consortium leader and signed mandate letters (Annex Ib) from the other consortium members should be provided.

I, the undersigned, being the authorised signatory of the above tenderer, hereby declare that we have examined and accept without reserve or restriction the entire content of the tender specifications and its annexes for the tender procedure referred to above.

We propose to provide the services requested in the tender specifications on the basis of our offer.

Signature
Name
Date

[1] Please indicate the official name of the company/organisation/institution etc.

Only if the tenderer is a natural person indicate his/her name: in this case the information for ‘contact person’ and for the ‘person authorised to represent the tenderer and to sign the contract’ must be left blank.

[2] Please indicate the official name of the company/organisation/institution etc.

Only if the consortium member is a natural person indicate his/her name: in this case the information for ‘contact person’ and for the ‘person authorised to represent the consortium leader’ must be left blank.

[3] Please indicate the official name of the company/organisation/institution etc.

[4] Please indicate the official name of the company/organisation/institution etc.

[5] Please indicate the official name of the company/organisation/institution etc.

Only if the subcontractor is a natural person indicate his/her name: in this case the information for ‘contact person’ and for the ‘person authorised to represent the subcontractor’ must be left blank.

[6] Please indicate the official name of the company/organisation/institution etc.

[7] Please indicate the official name of the company/organisation/institution etc.