part c application submission forms[1]

PART C

Application Submission Forms

Part C_Application Submission Forms of 21

Presentation of information by the Candidate’s: economic operator or association

The Forms foreseen within this section must be filled up accordingly.

The requested forms and statements must be signed in original, if not specified otherwise, by the authorized

persons or institutions, as appropriate.

The forms shall be filled in Applicants letterhead.

Each Candidate which submits an Application within this Procedure has the obligation to present the

information as listed below (following the specified order).

The Candidates are requested to submit one original and one CD including the scanned documents and all

the native files included in this Application.

The documents “Index/List of Content” presented within the Application will be used during Applications

opening meeting, for fulfilling the legal requirements related to the records of the documents presented by

each Candidate.

The file must be in word format (doc file) and will have the following structure:

Example:

The Application must clearly indicate each section in accordance with Index/List of Content and every page

must be numbered.

Item Title of the document (including no., date, where applicable) Page number in

the Application

1. ISO 9001:2008 Registration Certificate , AA 1234 101

CONTENT OF THE APPLICATION

1. “Index/ List of Content” of the documents submitted in this Application

[hard copy and electronic version including scanned originals and all native files]

2. General information about the Candidate - [in original]

3. In case of Association the information regarding each Candidate’s [in original]

4. Statement regarding the conflict of interest [in original]

5. Information regarding the Candidate’s personal situation

5.1. Eligibility statement - [in original]

5.2. Statement to indicate not being in any of the situations provided for by the art. 181 of Government

Emergency Ordinance no. 34/2006, with further amendments and supplementing - [in original]

5.3. Statement regarding the capacity of participant to the Procedure - [in original]

5.4. Certificate of good conduct/criminal record of the economic operator - [in original]

5.5. Litigation History - [in original]

6. Information related to the suitability to pursue the professional activity

6.1. Documents defining legal or company status - [copy]

6.2. Confirmation of company details issued by the National Trade Register Office or any other

equivalent document - [in original or certified copy]

7. Information related to the economic and financial standing

7.1. Statement of turnover for the preceding 3 years and associated supporting documents - [in original]

7.2. Extract from the balance sheets for the financial years 2008, 2009, 2010 and annex to indicate the

turnover, the profit and loss account - [copy]

7.3. Auditor Report for financial situations related to 2008, 2009, 2010 financial years - [copy]

7.4. Bank Details incl. rating of the bank including the name(s) and address(es) of your banker(s) or

referees of who may be contacted for financial references together with any other relevant

information [in original]

7.5. All Risk Insurance Certificate, if applicable - [copy]

7.6. Fixed undertaking to support third party economic and financial situation concluded in authentically

form, where applicable – [in original]

7.6.1. Eligibility statement filled by supporting third party - [in original]

7.6.2. Statement to indicate not being in any of the situations provided for by the art. 181 of

Government Emergency Ordinance no. 34/2006 with further amendments and

supplementing filled by supporting third party- [in original]

8. Information regarding the technical and professional capabilities

8.1. Statement regarding the main services performed for the last 3 years - [in original]

8.2. Detailed sheet – list of similar services in the last 3 years- [in original]

8.3. Statement regarding Candidate’s Infrastructure for proper performance of the services Framework

Agreement/Subsequent Contracts - [in original]

8.4. Statement regarding the percentage of subcontracted scope - [in original]

8.5. Statement related to the commitment of the Candidate to set-up an office in Romania, where

applicable - [in original]

8.6. The Candidate organisation chart - [in original]

8.7. Information on the number of managerial staff for the last 3 years - [in original]

8.8. Curriculum vitae for the managerial staff - [in original]

8.9. List of Key personnel - [in original]

8.10. Curricula vitae of the proposed Key personnel - [in original]

8.11. Men-power histogram for the last 3 years plus a forecast to 12/2012

8.12. Fixed undertaking to support third party technical and professional capabilities concluded in

authentically form, where applicable – [in original]

8.12.1. Eligibility statement - [in original]

8.12.2. Statement to indicate not being in any of the situations provided for by the art. 181 of

Government Emergency Ordinance no. 34/2006 with further amendments and

supplementing - [in original]

9. Information regarding the quality management system

9.1. Certificate of the Candidate’s Quality Management System, issued by the third party, ISO

9001:2008 certificate or equivalent - [copy]

9.2. Quality Management System Manual in force at the Application submission date - [copy]

9.3. Last audit report, which shall not be issued before December 2009 - [copy]

10. Information regarding the Candidate undertaking in the Procedure

10.1. Power of attorney of the person who signs this Application - [in original]

10.2. Association agreement - [in original]

11. Application Letter - [in original]

FORMS FOR SUBMITTING THE APPLICATION

Candidate's/Association Partner's Legal Name: [insert full name or letterhead]

2 - General Information about the Candidate

Date: [insert day, month, year]

Candidate's legal name : [insert full legal name]

In case of association, legal name of each partner:

[insert full legal name of each partner in association]

Candidate's year of establishment: [indicate year of establishment]

Candidate's legal (registered) address:

[insert street/ number/ town or city/ country]

Candidate's general description, including number of experience as Contractor in its own country or

internationally

Candidate's authorized representative information

Name: [insert full legal name]

Address: [insert street/ number/ town or city/ country]

Telephone/Fax numbers: [insert telephone/fax numbers, including country and city codes]

E-mail address: [indicate e-mail address]

Candidates of other nationality than Romanian, must state whether they are established in Romania in

accordance with applicable regulations (for information only)

Signature [a person or persons authorized to sign on behalf of the Candidate]


3 - Candidate's Party Information


[The following form shall be filled in by each of the Candidate's parties including partner(s) of an

association]

Association legal name: [insert full legal name]

Candidate’s Party legal name: [insert full legal name of Candidates Party]

Candidate Party's year of establishment: [indicate year of establishment]

Candidate Party's legal address :

[insert street/ number/ town or city/ country]

Candidate Party's authorized representative information

Name: [insert full legal name]

Address: [insert street/ number/ town or city/ country]

Telephone/Fax numbers: [insert telephone/fax numbers, including country and city codes]

E-mail address: [indicate e-mail address]



4 - Statement regarding the conflict of interest

Procedure for signing of the Framework Agreement.........................., contract notice no. [Insert the contract

notice no]

Referring to the information presented in the Part A – Instruction to Candidates, of the Qualification

Documents, for the above identified Procedure, I the undersigned empowered representative

of........................................................... (name, address of Candidate), hereby declare, under the sanctions of

being excluded from this Procedure and those applied for false declarations in public documents, that as

participant in this Procedure I am not in the situation described in art. 691 of the Government Emergency

Ordinance no. 34/2006 regarding the award of public procurement contracts, with further amendments and

supplementing.

I enclose to the present statement relevant information for verifying the potential conflict of interest situation,

as follows:

i. The list of the members of the Managing Board

(insert name 1, etc.)

ii. The list of the members of the Management (function and name)

(insert function - name 1, etc.)

iii. The list of associates/shareholders

(insert name 1, etc.)


Economic operator

................................

[a person or persons authorized to sign on behalf of the Candidate]


5.1 (and 7.6.1 and/or 8.12.1 if applicable) - Eligibility Statement


I, the undersigned, empowered representative of ........................ (name/address of Candidate submitting the

Application), hereby declare, under sanction of being excluded from this Procedure due to false declarations

in public documents, that I have not been convicted by final judgment of any court, within the last 5 years, for

participation in a criminal organization, corruption, fraud or money laundering.

I, the undersigned, hereby declare that provided information are correct within all details and understand that

OMV Petrom reserves the right to require, for the purpose of verifying and confirming my statements, any

evidences I may posses.

...................................................

Signature


Candidate's Name: [insert full name or letterhead]

5.2 (and 7.6.2 and/or 8.12.2 if applicable) - Statement to indicate not being in any of the situations

provided by the art. 181 of Government Emergency Ordinance no. 34/2006



Application), hereby solemnly declare that:

1. I am not bankrupt following a decision pronounced by a syndic judge

2. I have fulfilled my obligations relating to the payment of social security contributions and of taxes and

duties, in accordance with the legal provisions of Romania / of the country [delete as appropriate],

where I am established, i.e. ………………………… [indicate name, if other country], as at the closing

date for the submission of Applications.

3. I have not been guilty of breach of, nor have I failed to faithfully execute, other contracts awarded to

me, to such extent that the performance security was forfeited, during the period of time which begins

two (2) years before the closing date for the submission of Applications.

4. I have not been guilty of professional misconduct nor have I been convicted by a judgment which has

the force of res judicata of any offence concerning the professional conduct in the last 3 years before

date of submitting the Application.

5. I am not affected or likely to be affected by any conflict of interest in the present Procedure.

I, the undersigned, hereby declare that I am aware of the provisions of art. 292 „False statement” in

the Romanian Criminal Code related to «inaccurate declaration of truth made towards a body or state

agency or to any other unit of those mentioned by art. 145, in order to produce a legal consequence

for itself or for other, when in accordance with the law or with the circumstances, the declaration

serves to produce such consequence, is punished with imprisonment from 3 months to 2 years or a

fine».

[Any paragraph that does not apply should be deleted and the space below should be used to provide

clarifications.]

...................................................

Signature


Candidate's Name: [insert full name or letterhead]

5.3 - Statement regarding the capacity of participant to the Procedure


1 I, the undersigned, empowered representative of ........................ (name/address of Candidate submitting

the Application), hereby declare, under sanction of being excluded from this Procedure due to false

declarations in public documents, that for the purpose of the Procedure for the signing of the Framework

Agreement concerning Engineering and Management Services for Subsurface Facilities, organized by

OMV Petrom SA, I participate and submit my Application as:

economic operator - sole Candidate;

as associate within the Association ............ [insert name of Association] ..............;

2 I, the undersigned, hereby declare:

I am not a member of any group or network of economic operators;

I am a member of group/ network of economic operators whose list including all identification data I

hereby attach in the annex to this Statement.

[Tick the relevant option]

3 I, the undersigned, hereby declare I will immediately inform OMV Petrom should any modifications

intervene in the present statement, at any time during the Procedure or the Framework Agreement

duration.

4 I also hereby declare that provided information are complete and correct within all details and understand

that OMV Petrom reserves the right to require, for the purpose of verifying and confirming my statements

and documents accompanying the Application, any supplementary information.

5 I, the undersigned, hereby authorize any institution, commercial company, bank and other legal persons

to provide information to any authorized representatives of OMV Petrom, concerning any technical and

financial aspect related to our activity.

I, the undersigned, hereby declare that I am aware of the provisions of art. 292 „False statement” in the

Romanian Criminal Code related to «inaccurate declaration of truth made towards a body or state agency

or to any other unit of those mentioned by art. 145, in order to produce a legal consequence for itself or

for other, when in accordance with the law or with the circumstances, the declaration serves to produce

such consequence, is punished with imprisonment from 3 months to 2 years or with a fine».

...................................................

Signature



5.5 - Litigation History


[Please provide information on any litigation, arbitration or other dispute resolution procedure resulting from

contracts executed during the last 3 years or currently under execution. A form should be submitted for each

partner of association]

Year

Award FOR, or

AGAINST the

Economic

Operator

Name of ClientBrief contract description/

Disputed matter

Disputed amount

(Eur/lei) and time

extension (months)


Romanian Criminal Code related to «inaccurate declaration of truth made towards a body or state agency or

to any other unit of those mentioned by art. 145, in order to produce a legal consequence for itself or for other,

when in accordance with the law or with the circumstances, the declaration serves to produce such

consequence, is punished with imprisonment from 3 months to 2 years or a fine».

...................................................

Signature



7.1 - Statement of turnover


[The following table shall be filled in by the Candidate and by each partner of an association]

Annual general turnover data

Year Amount and Currency EUR equivalent

[indicate year] [insert amount and indicate currency] [insert amount in EUR equiv.]

Annual specific turnover data – Engineering & Management within Oil & Gas business

Year Amount and Currency EUR equivalent

[indicate year] [insert amount and indicate currency] [insert amount in EUR equiv.]

Annual specific turnover represents turnover from the activity of Engineering & Management services in Oil &

Gas Business, calculated as total certified payments received for activities in progress or completed.

I, the undersigned, hereby declare that I am aware of the provisions of art.292 „False statement” in the

Criminal Code related to «inaccurate declaration of truth made towards a body or state agency or to any other

unit of those mentioned by art. 145, in order to produce a legal consequence for itself or for other, when in

accordance with the law or with the circumstances, the declaration serves to produce such consequence, is

punished with imprisonment from 3 months to 2 years or a fine».

...................................................

Signature



8.1 - Statement regarding the main services performed for the last 3 years


[The following table shall be filled in by the Candidate and by each partner of an association]

[Please list the relevant projects carried out in the last 3 years. The table shall include following details: value

of the services, man-hours performed, the scope of work/subject matter, start and completion date, client and

country. List the contracts chronologically in accordance to their commencement (starting) dates. Use as

many lines as you consider appropriate].

I, the undersigned, authorized representative of......................................................... [insert full name of

Candidate] declare, subject to the sanctions enforced upon the act of forger in public documents, that:

1. the data presented in the table below reflects the reality.

2. the information supplied is accurate and complete in every detail

3. we understand OMV Petrom is entitled to request, for the purpose of verification and confirmation of

the declarations, statements and documents attached, any additional information for the purpose of

verification of the data in this statement.

4. hereby authorize any entity to supply information to the authorized representatives of OMV Petrom

regarding any information presented in relation to our experience.

Also, I declare that I am aware of the provisions of art. 292 „False statement” in the Criminal Code

related to «inaccurate declaration of truth made towards a body or state agency or to any other unit

of those mentioned by art. 145, in order to produce a legal consequence for itself or for other, when

in accordance with the law or with the circumstances, the declaration serves to produce such


No. Project name Client Country Project

Value*

[mio.EUR]

Engineering

&

Management

Man-hours

Start date End date

1. MM/YYYY MM/YYYY

* Project value to be understood as the value managed by the Candidate during execution of Candidate’s contract

...................................................

Signature


Candidate's/Association Partner's Legal Name: [insert full name or letter head]

8.2 - Detailed Sheet - Similar Experience Date: [insert day, month, year]

[The following table shall be filled in for each project performed by the Candidate, each partner of an

Association, and specialist sub-Contractors]

Information

Project reference number [insert project number]

Project name [insert project name]

Role in Contract

[check the appropriate box]

Single Contractor

Associate

Subcontractor

Total Contract Amount [insert total contract amount in

local currency]

EUR [insert total contract

amount in EUR equivalent]

If partner in an association, or

Subcontractor, specify participation in

total contract amount

[insert the

percentage]

[insert contract

amount in local

currency]

[insert contract amount in EUR

equivalent]

Description of the similarity

Scope of Work – brief description of

services provided

[insert ………………….]

Please indicate if the scope of Work was related to special areas of engineering activities:

- Field Re-Development (Yes / No)

- Produced and potable Water Treatment / Injection (Yes / No)

- Steam Generation, Distribution and Injection Systems (Yes / No)

- Heavy Oil Treatment (Yes / No)

- Polymer flooding (Yes / No)

HSE and risk assessment experience

HSE/Risk analysis documentation preparation (Yes / No)

Also, I declare that I am aware of the provisions of art. 292 „False statement” in the Romanian Criminal Code

related to «inaccurate declaration of truth made towards a body or state agency or to any other unit of those

mentioned by art. 145, in order to produce a legal consequence for itself or for other, when in accordance

with the law or with the circumstances, the declaration serves to produce such consequence, is punished with

imprisonment from 3 months to 2 years or a fine».

...................................................


8.3 - Candidate’s Infrastructure for proper performance of the services Framework

Agreement/Subsequent Contracts

Note: In case of an association this document will be presented only by the association.



Application), hereby declare, under sanction of being excluded from this Procedure due to false declarations

in public documents, that the information presented is real.

I, the undersigned, hereby declare that the information presented is correct and complete in every detail and I

understand that OMV Petrom is entitle to ask in view of verification and confirmation of the statements,

situations and documents which accompany the Application, any additional information in order to check

upon the present statement content.

I, the undersigned, hereby authorize any institution, company, bank or other legal persons to provide

information to representatives of OMV Petrom with regard to any technical and financial aspect linked to our

activity.

...................................................


List of Candidate’s Infrastructure for the proper performance of the services Framework Agreement/

Subsequent Contracts:

Infrastructure/ facility section: main/special office equipment,

software, office space, including office in Romania if applicable, etc.

Number

of

facilities

Description, brand

(if applicable)


Romanian Criminal Code related to «inaccurate declaration of truth made towards a body or state agency or

to any other unit of those mentioned by art. 145, in order to produce a legal consequence for itself or for other,

when in accordance with the law or with the circumstances, the declaration serves to produce such


...................................................



8.4 - Statement regarding the percentage of subcontracted scope

Note: In case of an association this document will be presented only by the association.


I, the undersigned, empowered representative of........................ [name/address of Candidate submitting the

Application], hereby declare, under sanction of being excluded from this Procedure due to false declarations

in public documents, that the information presented is the table below is real.

I, the undersigned, hereby declare that the information presented is correct and complete in every detail and I

understand that OMV Petrom is entitle to ask in view of verification and confirmation of the statements,

situations and documents which accompany the Application, any additional information in order to check

upon the present statement content.

Also, I declare that I am aware of the provisions of art. 292 „False statement” in the Romanian Criminal Code

related to «inaccurate declaration of truth made towards a body or state agency or to any other unit of those

mentioned by art. 145, in order to produce a legal consequence for itself or for other, when in accordance with

the law or with the circumstances, the declaration serves to produce such consequence, is punished with

imprisonment from 3 months to 2 years or a fine».

I declare that the sub-contracted services resulted from each Subsequent Contract awarded based on the

Framework Agreement will not exceed 30% of the subsequent contract value.

...................................................

Signature



Candidate’s Party Legal Name: [insert full name or letter head]

8.9 - List of Key personnel Date: [insert day, month, year]

Name Job title / Discipline Level of

Education

General

professional

experience

[years]

Specific

experience in

Steam Process

and/or Water

Treatment

[Yes/No]

Specific

experience in

Construction

Management

[Yes/No]

...................................................

Signature


8.10 - Curriculum vitae of the proposed Key personnel

(the proposed resumes shall follow the below structure and contain minimum the following information)

NAME

Date and Place of Birth

Country

EDUCATION

Languages

INFORMATION TECHNOLOGY – IT skills

PROFESSIONAL EXPERIENCE

General professional experience:

[insert the Company name, Job title, Client name, Project name and period (MM/YYYY), Country, value of

the project and brief description of responsibilities]

Experience in Steam Process and/or Water Treatment (applicable for Process Engineers):



Experience in Construction Management (applicable for Costruction Manager):




11 - Application Letter


Application No. and title: [insert number and title]

To: SC OMV PETROM SA

We, the undersigned, apply to be qualified for the referenced mentioned above and declare that:

(a) we have examined and have no reservations to the Qualification Documents, including Addendum(s)

No(s), issued in accordance with Instructions to Candidates paragraph “Addendum to Qualification

Documents”: [insert the number and issuing date of each addendum].

(b) we confirm that, including subcontractors or suppliers, for any part of the Framework Agreement/

Subsequent Contracts resulting from this Procedure, we do not have any conflict of interest, as defined

in Instruction to Candidates,

(c) we, plan to subcontract the following key activities and/or parts of the services:

[insert any of the key activities identified in Part B of the Qualification Document which the Candidate

intends to subcontract]

Our Application is submitted on behalf of the following:

Name(s) of Candidate(s)

Leader

Member of association 2*

Member of association 3 *

……….

* add/delete additional lines for partners as appropriate. Note that subcontractors are not considered

as partners for the purposes of this Qualification Procedure. If this Application is being submitted by

an individual Candidate – economic operator, the name of the Candidate should be entered as

'leader' (and all other lines should be deleted)

We agree that our present Application shall be valid from the Applications submission date, for a period

equal to 90 days, that shall bind us and that it may be accepted at any time prior to the expiry of the said

period.

Note: All blank fields must be completed by the Candidate or by the Candidate’s Representative.

We, as Candidate in this Procedure, declare that no attempt has been made or will be made by us to

induce any other concern to submit or not to submit an application for the purpose of restricting

competition.

If our Application is accepted, we undertake to participate with an offer following the Invitation to Bid.

We understand that OMV Petrom is not bound to proceed with this Procedure and that it reserves the

right to cancel the Procedure at any time and that OMV Petrom is neither bound to accept any

Application that you may receive nor to invite the shortlisted Candidates to bid for the Framework

Agreement subject of this Procedure, without incurring any liability to the Candidates.

Signature of Candidate or of Candidate’s

Representative......................................................................

Name of signatory

Capacity of signatory