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PRE-QUALIFICATION/REGISTRATION OF SUPPLIERS FOR

SUPPLY/PROVISION OF GOODS AND SERVICES

BI-ANNUAL TENDER AND PREQUALIFICATION FOR

FINANCIAL YEARS 2014-2015 & 2015-2016

Category No……………….................................

CLOSING DATE: 18th SEPTEMBER 2014 AT 11.30 A.M

1 | K N C H R P R E Q U A L I F I C A T I O N 2 0 1 4 / 2 0 1 5 – 2 0 1 5 / 2 0 1 6

Table of Contents Pages

1. TENDER NOTICE……………………………………………………………..2-4

2. PRE-QUALIFICATION INSTRUCTIONS ………………………………….5-6

3. BRIEF CONTRACT REGULATIONS……………………………………....7

4. PRE-QUALIFICATION DATA INSTRUCTIONS….……………………….8-10

5. FORM PQ – 1 PRE-QUALIFICATION DOCUMENTS…….……………....11

6. FORM PQ – 2 PREQUALIFICATION DATA…………….………….……..12-13

7. FORM PQ – 3 SUPERVISORY PERSONNEL…….……………….……….14-17

8. FORM PQ – 4 FINANCIAL POSITION……………..……………………….18

9. FORM PQ – 5 CONFIDENTIAL BUSINESS QUESTIONNAIRES………19-20

10. FORM PQ – 6 PAST EXPERIENCE…………..………………………….....21

11. FORM PQ – 7 LITIGATION HISTORY…………………………….………22

12. FORM PQ – 8 SWORN STATEMENT……………………………….……23


Invitation for Bid/Tender Notice

Date: 29th August 2014

RE: Pre-qualification of Suppliers for Goods and Services for the Financial Years 2014/2015 and

2015/2016.

The KNCHR invites interested eligible suppliers to apply for the Prequalification for Supply and Provision

of the listed Goods and services for the financial years 2014/2015 and 2015/2016 on a “as and when

required basis”.

KNCHR invites applications from interested eligible firms for the prequalification of suppliers and service

providers for the under listed categories for the financial years 2014/2015 and 2015/2016

NO. CATEGORY NUMBER ITEMS DESCRIPTION

1 KNCHR/01/2014/2015 & 2015/2016 Supply of General Stationery

2 KNCHR/02/2014/2015 & 2015/2016 Supply And Delivery of Computers, Computer Hardware, Printers, Photocopiers,

Servers and ICT related Equipments.

3 KNCHR/03/2014/2015 & 2015/2016 Supply of Office Furniture and Fittings

4 KNCHR/04/2014/2015 & 2015/2016 Supply of Motor Vehicle Tyres, Tubes, and Batteries

5 KNCHR/05/2014/2015 & 2015/2016 Supply of Photocopier Toners

6 KNCHR/06/2014/2015 & 2015/2016 Supply of Electronics Equipments (Cameras, Voice Recorders, cell phones, etc)

7 KNCHR/07/2014/2015 & 2015/2016 Provision of Car Hire Services in Nairobi, Mombasa, Wajir, Kisumu and Kitale

8 KNCHR/08/2014/2015 & 2015/2016 Provision of Telecommunication Equipment, Airtime and Accessories

9 KNCHR/9/2014/2015 & 2015/2016 Provision of hotel accommodation, seminar facilities and catering Services

10 KNCHR/10/2014/2015 & 2015/2016 Provision of Outdoor branding services

11 KNCHR/11/2014/2015 & 2015/2016 Provision of Asset Tagging and Labelling Services

12 KNCHR/12/2014/2015 & 2015/2016 Design and Supply of branded promotional materials (T-shirts, Caps, carrier bags,

banners, etc)

13 KNCHR/13/2014/2015 & 2015/2016 Provision of Travel Agency Services – IATA/KATA Registered Firms

14 KNCHR/14/2014/2015 & 2015/2016 Provision of Taxi Services – Nairobi, Mombasa, Kisumu, Eldoret and Kitale

15 KNCHR/15/2014/2015 & 2015/2016 Provision of Insurance Brokerage Services

16 KNCHR/16/2014/2015 & 2015/2016 Provision of General Printing Services

17 KNCHR/17/2014/2015 & 2015/2016 Provision of Bulk Photocopying and Binding Services

18 KNCHR/181/2014/2015 & 2015/2016 Provision of Human rights related Consultancy services and

facilitation/Rapporteuring/Report writing and Editing services

19 KNCHR/19/2014/2015 & 2015/2016 Provision of entertainment services (DJs, MC’s, Bands, Musicians, theatre groups, etc)

20 KNCHR/20/2014/2015 & 2015/2016 Repair and servicing of motor vehicles: Ministry of Transport & Infrastructure approved

garages/dealers only

21 KNCHR/21/2014/2015 & 2015/2016 Provision of General Cleaning Services in Nairobi, Mombasa, Kitale and Wajir

22 KNCHR/22/2014/2015 & 2015/2016 Repair and maintenance of office equipments; Servers, UPS Computers, LAN, Printers

& Photocopiers, PABX, Telephone heads and FAX machines

23 KNCHR/23/2014/2015 & 2015/2016 Provision of Team Building Consultancy Services

24 KNCHR/24/2014/2015 & 2015/2016 Provision of Photography and Videography services, production of documentaries, TV

and Radio Infomercial services

25 KNCHR/25/2014/2015 & 2015/2016 Provision of creative design production services.( Including Cartoonists, Animators,

Publication of layout Design)


26 KNCHR/26/2014/2015 & 2015/2016 Provision of Translation & Sign language interpretation services

27 KNCHR/27/2014/2015 & 2015/2016 Provision of Event Management Services, Tents, Chairs, Stage Assembly & Sound

(P.A) Services and decor services Road Show rigs

28 KNCHR/28/2014/2015 & 2015/2016 Provision of Legal Services

29 KNCHR/29/2014/2015 & 2015/2016 Provision of Minor Office Maintenance works e.g. Repairs, plumbing and electrical

works

30 KNCHR/30/2014/2015 & 2015/2016 Supply of Computer Software and networking equipments

31 KNCHR/31/2014/2015 & 2015/2016 Provision of Security/Guarding services in Mombasa and Wajir

32 KNCHR/32/2014/2015 & 2015/2016 Provision of Courier Services; Letters & Parcels

33 KNCHR/33/2014/2015 & 2015/2016 Provision of Asset Valuation Services

34 KNCHR/34/2014/2015 & 2015/2016 Provision of Monitoring & Evaluation Consultancy Services

35 KNCHR/35/2014/2015 & 2015/2016 Provision of Internet Services

The pre – qualification documents must be accompanied by the following:-

1. Copy of certificate of incorporation/Registration

2. List and value of all contract works performed in the last 2 years

3. Contacts of at least 2 major clients who may be contacted for further information on these contracts

4. Qualification and experience of key personnel

5. Authority to seek reference from bankers and clients

6. Certificate copies of PIN and VAT registration certificate

7. Physical address

8. Provide audited accounts for the last 2years

NB: People with disabilities, Youth & Women enterprises are encouraged to apply in all categories qualified

and Must attach the following:-

a) Attach copy of business Registration Certificate, PIN Certificate & VAT Certificate, Tax compliance,

Yagpo Certificate

b) Previous experience is NOT a requirement.

The below listed documents are mandatory for the two categories stated above:-

(i) Copy of certificate of incorporation/registration

(ii) Copy of valid Business permit

(iii) Letters of recommendation from two of your major clients

(iv) Company profile

(v) Tax compliance, VAT, PIN


The pre – qualification documents must be accompanied by the following:-

1. List and value of at least five contracts successfully implemented in the last two years.

2. Contacts of at least two major clients who may be contacted for further information on these contracts

3. Qualification and experience of key personnel

4. Authority to seek reference from bankers and clients

5. Physical address

6. Provide audited accounts for the last two years

NB: People with disabilities, Youth & Women enterprises are encouraged to apply in all categories qualified

and Must attach the following:-

c) Attach copy of business Registration Certificate, PIN Certificate & VAT Certificate, Tax compliance, Yagpo

Certificate

d) Previous experience is NOT a requirement

The below listed documents are mandatory for the two categories stated above:-

1. Copy of certificate of incorporation/registration

2. Letters of recommendation from two of your major clients

3. Company profile

4. Tax compliance, VAT and PIN Certificate

Tender/Pre-qualification documents may be obtained from the KNCHR offices, located at 1st Floor CVS Plaza, along

Kasuku/Lenana Road Junction in Nairobi, Mombasa office along Panal Freighters lane off Haile Selassie Road,

Kitale Office at Ambwere Plaza Ground Floor, Wajir Office along Air Strip Road and Kisumu Office at Central

Square Building 2nd Floor Oginga Odinga Street between 8.30am and 4.00pm during working hours Monday to

Friday, at a non- refundable fee of Kshs.1,000/- per document payable in cash or bankers’ cheque or be downloaded

free of charge from www.knchr.org

Duly completed Tender/pre-qualification document in plain sealed envelopes marked “pre-qualification of suppliers”

with detail of Pre-qualification Category Number should be addressed to:

The Commission Secretary

Kenya National Commission on Human Rights,

1st Floor CVS Plaza, Lenana Road,

P.O Box 74359-00200,

Nairobi-Kenya

or be deposited in the tender box situated at the KNCHR Nairobi Office 1st Floor CVS Plaza, along

Kasuku/Lenana Road Junction on or before 18th September 2014 at 11.30 am. Tender /Pre-Qualification

documents will be opened immediately thereafter in the presence of the tenderers or their representatives who choose

to attend. Any document received after the due time and date shall be rejected and returned.

Patricia M. Nyaundi

COMMISSION SECRETARY

http://www.knchr.org/


PRE-QUALIFICATION INSTRUCTIONS

1.1 Introduction

KNCHR would like to invite interested candidates who must qualify by meeting the set criteria as

provided to perform the contract of supply and delivery or provision of goods, works and services to

the Government.

1.2 Pre-qualification Objective

The main objective is to supply and deliver assorted items and also provide works and services under

relevant tenders/quotations to the KNCHR for the period; 2014/2015 and 2015/2016 ending 30th

June, 2016.

1.3 Invitation of Pre-qualification

Suppliers and Contractors registered with Registrar of Companies under the Laws of Kenya in

respective merchandise or services are invited to submit their PRE-QUALIFICATION documents to

KNCHR so that they may be pre-qualified for submission of bids or quotations. Bids will be

submitted in complete lots singly or in combination. The prospective suppliers/contractors are

required to submit the mandatory information for pre-qualification.

1.4 Experience

Prospective suppliers and contractors must have carried out successful supply and delivery of similar

items/services to Government institutions of similar size and complexity. However for firms

registered under preference groups are exempted in this requirement. Potential suppliers/contractors

must demonstrate the willingness and commitment to meet the pre-qualification criteria.

1.5 Pre-qualification Document

This document includes questionnaire forms and documents required of prospective candidates.

1.6 In order to be considered for pre-qualification, prospective candidates must submit all the

information as herein requested.

1.7 Distribution of Pre-qualification Documents

Duly Completed pre-qualification data and other requested information shall be submitted, so as to

reach: The Commission Secretary, Kenya National Commission on Human Rights, 1st Floor CVS

Plaza, Lenana Road, P. O Box 74359-00200, Nairobi-Kenya Not later than 18th September 2014 at

11.30 a.m.


1.8 Questions Arising from Documents

Questions that may arise from the pre-qualification documents should be directed to The

Commission Secretary whose address is given in part 1.7

1.9 Additional Information

KNCHR reserves the right to request submission of additional information from prospective

bidders.

1.10 Request for quotations/Tenders will be made available only to those bidders whose qualifications

meet a minimum score of 70% upon evaluation.


2 BRIEF CONTRACT REGULATIONS/GUIDELINES

2.1 Taxes on Imported Materials

The Supplier/Contractor will have to pay custom duty and VAT as applicable for all imported

materials to be supplied unless the item(s) is/are donor funded.

2.2 Customs Clearance

The contractors shall be responsible for custom clearance of their imported goods and materials.

2.3 Contract Price

The contract shall be of unit price type or cumulative of computed unit price and quantities required.

Quantities may increase or decrease as determined by demand on the authority of the client’s

Accounting Officer or Tender Committee. Prices quoted should be inclusive of all delivery charges.

2.4 Payments

All local purchase shall be on credit of a minimum of thirty (30) days or as may be stipulated in the

Contract Agreement.


3. PRE-QUALIFICATION DATA INSTRUCTIONS

3.1 Pre-qualification data forms

The attached questionnaire forms PQ-1, PQ-2, PQ-3(a), PQ-3(b), PQ-4, PQ-5, PQ-6, PQ-7, PQ-8,

are to be completed by prospective suppliers/contractors who wish to be pre-qualified for submission

of application for the specific tender.

3.1.1 The pre-qualified application forms which are NOT filled out completely and submitted in the

prescribed manner will not be considered. All the documents that form part of the proposal must

be written in English and in ink.

3.2 Qualification

3.2.1 It is understood and agreed that the pre-qualification data on prospective bidders is to be used by the

KNCHR in determining, according to its sole judgment and discretion, the qualifications of

prospective bidders to perform in respect to the Tender Category as described by the client.

3.2.2 Prospective bidders will not be considered qualified unless in the judgment of the KNCHR that they

possess capability, experience, qualified personnel available and suitability of equipment and net

current assets or working capital sufficient to satisfactorily execute the contract for goods/services.

3.3 Essential Criteria for Pre-qualification

3.3.1 (a) Experience: Prospective bidders shall have at least 2 years experience (preference group

exmpted) in the supply of goods, works, services and allied items in case of potential

supplier/contractor should show competence, willingness and capacity to service the contract.

(b) Prospective candidates require special experience and capability to organize supply and delivery

of items, or services at short notice.

3.3.2 Personnel

The names and pertinent information and detailed CVs of the key personnel for individual or group

to execute the contract must be indicated in form PQ-3.


3.3.3 Financial Condition

The Candidate’s financial condition will be determined by latest financial statement submitted with

the prequalification documents as well as letters of reference from their bankers regarding

suppliers/contractors credit position. Potential suppliers/contractors will be pre-qualified on the

satisfactory information given.

3.3.4 Special consideration will be given to the financial resources available as working capital, taking

into account the amount of uncompleted orders on contract and now in progress. Data to be

filled/provided on Form PQ-4. However, potential bidders should provide evidence of financial

capability to execute the contract.

3.3.5 Past Performance

Past performance will be given due consideration in pre-qualifying bidders. Letter of reference from

past customers should be included in Form PQ-6

3.4 Statement

Applicants must include a sworn statement Form PQ-8 by the Tenderers ensuring the accuracy of the

information given.

3.5 Withdrawal of Prequalification

Should a condition arise between the time the firm is pre-qualified to bid and the bid opening date

which in the opinion of the client/KNCHR could substantially change the performance and

qualification of the bidder or his ability to perform such as but not limited to bankruptcy, change in

ownership or new commitments, the KNCHR reserves the right to reject the tender from such a

bidder even though he was initially pre-qualified.

3.6 The firm must have a fixed Business Premise and must be registered in Kenya, with certificate of

Registration, Incorporation/Memorandum and Articles of Association, copies of which must be

attached.


3.6.1 The firm must show proof that it has paid all its statutory obligations and have current Tax

Compliance Certificate

3.7 Prequalification Criteria

Required Information Form Type Points Score

1. Registration Documentation PQ-1 12

2. Pre-qualification Data PQ-2 10

3. Supervisory Personnel PQ-3(a) or 3(b) (fill one part but not both) 30

4. Financial Position PQ-4 10

5. Confidential Report PQ-5 10

6. Past Experience PQ-6 18

7. Litigation History PQ-7 5

8. Sworn Statement PQ- 8 5

TOTAL 100

3.8 The qualification shall be 70 points and above.

NB. 1. Part PQ 3(a) applicable to all suppliers except consultancy firms.

2. Part PQ 3(b) applicable to consultancy firms only.


FORM PQ-1 PRE-QUALIFICATION

All firms must provide:-

1. Copies of Certificate of Registration.

2. Copy of VAT Registration Certificate.

3. Tax Compliance Certificate from Kenya Revenue Authority

NB: Failure to produce the compliance certificate will lead to automatic disqualification

thus no further evaluation of your application.

4. Copies of Pin Certificate of firm/company/individual.

5. Copy of current Trade License, where applicable and

6. Firms who want to register for Supply of Computers, Laptops, Servers, Ups, Printers, Scanners,

Software, Accessories and Consumables should attach dealership/Authorization letters from the

manufacturers.

NB: Failure to provide the authorization letters will lead to automatic disqualification of the

applicant.

(12 points)


FORM PQ-2 - PRE-QUALIFICATION DATA

REGISTRATION OF SUPPLIERS APPLICATION FORM

1. I/We …………………………………………………………hereby apply for registration as supplier(s)

(Name of Company/Firm)

of ……………………………………………………………………………………………………………

(Item Description)

……………………………………………………………………………………………………………

(Category No.)

Post Office Address……………………………………………………………………………………..

Town ……………………………………………………………………………………………………

Street ……………………………………………………………………………………………………

Name of building ……………………………………………………………………………………….

Room/Office No.……………………………………………Floor No. ……………………………….

Telephone Nos.…………………………………………………………………………………………

Full Name of applicant………………………………………………………………………………….

Other branches location …………………………………………………………………………………

2. Organization & Business Information

Management Personnel ……………………………………………………………………………….

President (Chief Executive) …………………………………………………………………………..

Secretary ………………………………………………………………………………………………

General Manager ……………………………………………………………………………………..

Treasurer ………………………………………………………………………………………………

Other ………………………………………………………………………………………………….


Partnership (if applicable)

Names of Partners

3. Business founded or incorporated………………………………………………………….

4. Under present management since…………………………………………………………..

5. Net worth equivalent Kshs.…………………………………………………………………

6. Bank reference and address ………………………………………………………………...

…………………………………………………………………………………………………

7. Bonding company reference and address ……………………………………………………

8. Enclose copy of organization chart of the firm indicating the main fields of activities……..

…………………………………………………………………………………………………

9. State any technological innovations or specific attributes which distinguish you from your competitors

………………………………………………………………………………………

………………………………………………………………………………………………...

…………………………………………………………………………………………………

10. Indicate terms of trade/sale…………………………………………………………………..

(10 Points)


PQ-3 (a) SUPERVISORY PERSONNEL (applicable to all suppliers except consultancy services)

Name…………………………………………………………………………………………………

Age…………………………………………………………………………………………………..

Academic Qualification………………………………………………………………..…………….

……………………………………………………………………………………………………….

Professional Qualification……………………………………………………………………………

……………………………………………………………………………………………………….

Length of service with Contractor or Supplier position held………………………………………..

…………………………………………………………………………………………………………

(Attach copies of certificates of key personnel’s in the organization)

(30 Points)


PQ-3 (b) KEY PERSONNEL (applicable ONLY to suppliers applying for consultancy services)

Consultant’s Experience

[Using the format below, provide information on at least ten different consultancies that you have

participated which are similar to the one you are applying for in this prequalification.]

Assignment name: Approx. Value of the contract (in current Ksh.)

Country:

Location within country:

Duration of assignment (months)

Name of Client: Total No. Of staff-months of the assignment:

Address: Approx. Value of the services provided by your firm under

the contract (in current Ksh.):

Start date (month/year):

Completion date (month/year):

No. Of professional staff-months provided by associated

Consultants:

Name of associated Consultants, if any:

Name of senior professional staff of your firm involved and

functions performed (indicate most significant profiles such

as Project Director/Coordinator, Team Leader):

Narrative description of Project

Description of actual services provided by your staff within the assignment:

Relevant documents attached

(20 points)


Consultants Qualifications

[Using the format below, provide information on at least five different key/ Technical staff

employed/associated with the firm applying for this prequalification.]

CURRICULUM VITAE (CV) FOR PROPOSED PROFESSIONAL STAFF

1. Position of the Staff member in the company [only one candidate shall be nominated for each

position]:

2. Name of Staff [Insert full name]:

4. Date of Birth: Nationality:

5. Education [Indicate college/university and other specialized education of staff member, giving names

of institutions, degrees obtained, and dates of obtainment]:

6. Membership of Professional Associations:

7. Other Training [Indicate any other relevant training other than those mentioned under 5 above]:

8. Countries of Work Experience: [List countries where staff has worked in the last ten years]:

9. Languages [For each language indicate proficiency: good, fair, or poor in speaking, reading, and

writing]:

10. Employment Record [Starting with present position, list in reverse order every employment held by

staff member since graduation, giving for each employment dates of employment, name of employing

organization, positions held.]:

NB: Attach copies of relevant certificates and testimonials


13. Certification:

I, the undersigned, certify that to the best of my knowledge and belief, this CV correctly describes me,

my qualifications, and my experience. I understand that any wilful misstatement described herein

may lead to my disqualification or dismissal, if engaged.

Date:

[Signature of staff member or authorized representative of the staff] Day/Month/Year

Full name of authorized representative: ___________________________________________

(10 points)


PQ-4 - FINANCIAL POSITION AND TERMS OF TRADE

(1) Attach a copy of firm’s two certified financial statements giving summary of assets and current

liabilities/or any other financial support.

(2) Attach letters of reference from the bankers regarding supplier’s credit position.

(10 Points)

FORM PQ-5

REPUBLIC OF KENYA

CONFIDENTIAL BUSINESS QUESTIONNAIRE (6 points)

You are requested to give the particulars indicated in Part I and either Part 2 (a), 2 (b) or 2 (c)

whichever applies to your type of business.

You are advised that it is a serious offence to give false information on this form

Part I- General :

Business Name ………………………………………………………………………………....

Location of business premises………………………………………………………………….

Plot No. ………………………………… Street/Road…………………………………………

Postal Address………………………………….Tel. No…………………………………….....

Nature of business……………………………………………………………………………….

Current Trade License No………………………………….Expiring date…………………….

Maximum value of business which you can handle at any one time: Kshs…………………….

Name of your bankers……………………………………Branch ……………………………..

Part 2 (a) – Sole Proprietor

Your name in full……………………………………….…………….Age………….…….

Nationality………………………………Country of origin……………………………….

*Citizenship details…………………………………………………………………………

Part 2 (b) Partnership

Given details of partners as follows:

Name Nationality Citizenship Details Shares

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………


Part 2 ( c) – Registered Company:

Private or Public…………………………………………………………………….

State the nominal and issued capital of company-

Nominal Kshs.………………………………..

Issued Kshs.…………………………………..

Given details of all directors as follows:-

Name Nationality Citizenship Details Shares

1. …………………………………………………………………………………………

2. …………………………………………………………………………………………

3. …………………………………………………………………………………………

4. …………………………………………………………………………………………

5. ……………………………………………………………………………………….

Date ……………………………………..….Signature of Candidate……………………….

*if Kenya Citizen, indicate under “Citizenship Details” whether by Birth, Naturalization or Registration

(10 Points)


FORM PQ-6 - PAST EXPERIENCE

NAMES OF OTHER CLIENTS AND VALUES OF CONTRACT/ORDERS –

(PREFERENCE GROUP EXEMPTED)

i) Name of Client (organization) ………………………………………………………

ii) Address of Client (organization) ……………………………………………………

iii) Name of Contact Person at the client (organization) ……………………………….

iv) Telephone No. of Client …………………………………………………………….

v) Value of Contract ……………………………………………………………………

vi) Duration of Contract (date) …………………………………………………………

(Attach documental evidence of existence of contract)

2. Name of 2nd Client (organization)




iv) Telephone No. of Client ……………………………………………………………

v) Value of Contract …………………………………………………………………..



3. Name of 3rd Client (organization)




iv) Telephone No. of Client ……………………………………………………………

v) Value of Contract …………………………………………………………………..



4. Others ………………………………………………………………………………………

(18 Points)


FORM PQ-7 - LITIGATION HISTORY

Name of Contract Supplier

Contractors/Suppliers should provide information on any history of litigation or arbitration resulting

from contracts executed in the last five years or currently under execution.

YEAR AWARD FOR OR

AGAINST

NAME OF CLIENT CAUSE

OF LITIGATION AND

MATTER IN DISPUTE

DISPUTED AMOUNT

(CURRENT VALUE,

KSHS. EQUIVALENT

(5 Points)


FORM PQ-8 - SWORN STATEMENT

Having studied the pre-qualification information for the above project we/I hereby state:

a. The information furnished in our application is accurate to the best of our knowledge.

b. That in case of being pre-qualified we acknowledge that this grants us the right to

participate in due time in the submission of a tender or quotation on the basis of

provisions in the tender or quotation documents to follow.

c. We enclose all the required documents and information required for the pre-qualification

evaluation.

Date …………………………………………………………………………………………

Applicant’s Name …………………………………………………………………

Represented by …………………………………………………………………………

Signature …………………………………………………………………………………

(Full name and designation of the person signing and stamp or seal)

(5 Points)