CONSULTANT PRE-QUALIFICATION FORM Doc. # CD-FRM-009B Revision # 4.3 Date 10-Nov-2019 Page 1 of 130 Owner COMMERCIAL DEPT GUIDELINES FOR PRE-QUALIFICATION COMPLETION AND SUBMISSION 1 All Sections must be completed in order to be considered for pre- qualification. 2 An explanation must be provided when certain questions cannot be fully answered. 3 Supplementary pages may be photocopied and inserted if required.
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CONSULTANTPRE-QUALIFICATION FORM
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 1 of 79
Owner COMMERCIAL DEPT
GUIDELINES FOR PRE-QUALIFICATION COMPLETION AND SUBMISSION
1 All Sections must be completed in order to be considered for pre-qualification.2 An explanation must be provided when certain questions cannot be fully answered.3 Supplementary pages may be photocopied and inserted if required.4 Completed PQ Form together with your company brochure and supplementary documents are to be
submitted to EMPOWER in soft copy (scanned document in PDF format on CD), marked for the attention of the Commercial Director. Note: Soft Copy to have separate files for each Section of the PQ Document together with separate files for each supporting document. Submission in hard copy is not acceptable.
CONSULTANTPRE-QUALIFICATION FORM
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 2 of 79
Owner COMMERCIAL DEPT
5 Please retain a copy of your complete submission.
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
1.1. Company Name: Info Info
1.2. Telephone Number: Info Info
1.3. Fax Number: Info Info
1.4. Website Address: Info Info
CONSULTANTPRE-QUALIFICATION FORM
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Revision # 4.3
Date 10-Nov-2019
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Owner COMMERCIAL DEPT
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
1.5. Company E-mail: Info Info
1.6. Postal Address: Info Info
1.7. Name of Company GM No of years as GM Info Info
1.8. GM Contact No Info Info
1.9. GM Email Info Info
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
1.10. Main Office Location Info Info
1.11. Subsidiary Offices Location/s Info Info
1.12. UAE Commercial Licence No:1 Info Infor
1.13. Emirate of Commercial Licence: Info Info
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
1.14. Commercial Licence Expiry Date: Info Info
1.15. Chamber of Commerce Registration No:2 Info Info
1.16. Date Company Established: Info Info
1 Attach Copy of UAE Commercial Licence
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
1.17. VAT Registration No:3 Info Info
1.18. Status of Business: Corporation Partnership Individual LLC Other Info Info
1.19. Local Sponsor Details Info Info
NAME NATIONALITY PERCENTAGE OF SHARE CONTACT TELEPHONE
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Owner COMMERCIAL DEPT
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
1.20. Name of Parent Company (if any)
1.21. Is Parent Company willing to Provide Parent Company Guarantee? Yes No Info Info
2 Attach Copy of Chamber of Commerce Registration Certificate
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
1.22. Associated / Subsidiary Companies No Yes (if “Yes” insert details below) Info Info
COMPANY NAME GENERAL MANAGER CONTACT NUMBER % STAKE HELD & RELATIONSHIP
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
1.23. Names of people in your company who are authorised to sign legally binding contracts with third parties4 Info Info
NAME DESIGNATION E-MAIL ADDRESS TELEPHONE
3 Attach Copy of UAE VAT Registration Certificate
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Owner COMMERCIAL DEPT
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
1.24. Does your company have any affiliated company or joint venture company or partnership company or any association company, which company(ies) currently providing product or services to Empower, if so please provide the following details of those Company(ies);
NAME OF THE ASSOCIATED COMPANY
CONTACT DETAILS TYPE OF PRODUCT OR SERVICES
NAME OF THE ASSOCIATED COMPANY
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
1.25 Does any person in your company have any involvement with any other company(ies), which company already providing product(s) and Service(s) to Empower, if so please provide the following information;
4 Attach copies of legally notarized and attested Powers of Attorney
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
1. COMPANY DATA
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
NAME OF PERSONNAME OF THE ASSOCIATED
COMPANY CONTACT DETAILSTYPE OF PRODUCT OR
SERVICES
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2. INFORMATION FOR EMPOWER’S TECHNICAL/PROJECTS DEPARTMENT(Completion of all Sections is Mandatory) (Score to be filled by Empower Projects Dept.)
BENCHMARK
SCORE (by
Empower)
2.1. Number of Employees MANAGERIAL TECHNICAL ADMINISTRATIVE PRODUCTION TOTAL
5
2.2. Type of Projects for Which Consultant Seeks Prequalification
VENDOR TO TICK CATEGORY OF PQ APPLICATION
ACCEPTED BY EMPOWER
REJECTED BY EMPOWER
(a) District Cooling Plants Info Info
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2. INFORMATION FOR EMPOWER’S TECHNICAL/PROJECTS DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Projects Dept.)
BENCHMARK
SCORE (by
Empower)
(b) Semi-Permanent Plants Info Info
(c) Chilled Water Networks Info Info
(d) Civil Works Info Info
(e) Buildings (Mixed Use Development) Info Info
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2. INFORMATION FOR EMPOWER’S TECHNICAL/PROJECTS DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Projects Dept.)
BENCHMARK
SCORE (by
Empower)
(f) Other (Specify) Info Info
(g) Other (Specify) Info Info
2.3. What is the largest contract (by value) executed by your company in the last 3 years
Value in AED [Provide brief Project Description] 5
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2. INFORMATION FOR EMPOWER’S TECHNICAL/PROJECTS DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Projects Dept.)
BENCHMARK
SCORE (by
Empower)
2.7. Projects Executed for Empower in last 4 Years 5
PROJECT NAME TYPE OF WORK PROJECT VALUE YEAR AWARDED
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2. INFORMATION FOR EMPOWER’S TECHNICAL/PROJECTS DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Projects Dept.)
BENCHMARK
SCORE (by
Empower)
2.8. Projects Executed for Government of Dubai Entities in the last 4 years? 4
GOVERNMENT ENTITY
PROJECT NAME TYPE OF WORK PROJECT VALUE YEAR AWARDED
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2. INFORMATION FOR EMPOWER’S TECHNICAL/PROJECTS DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Projects Dept.)
BENCHMARK
SCORE (by
Empower)
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2. INFORMATION FOR EMPOWER’S TECHNICAL/PROJECTS DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Projects Dept.)
BENCHMARK
SCORE (by
Empower)
2.9. How many Projects have you won in the last 4 years in the value categories reflected below? 5
PROJECT VALUE CATEGORY MOST RECENT YEAR
YEAR 2 YEAR 3 YEAR 4
Projects < AED 100m > AED 50m
Projects < AED 50m > AED 20m
Projects < AED 20m > AED 10m
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2. INFORMATION FOR EMPOWER’S TECHNICAL/PROJECTS DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Projects Dept.)
BENCHMARK
SCORE (by
Empower)
Projects < AED 10m > AED 5m
Projects < AED 5m > AED 1m
Projects < AED 1M
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2. INFORMATION FOR EMPOWER’S TECHNICAL/PROJECTS DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Projects Dept.)
BENCHMARK
SCORE (by
Empower)
2.10. Please provide references from the Client in respect of the last 5 projects that you have completed [List details below and provide written references from each identified party. The reference should be on a company letterhead and should state the name of the project, the value of the project, whether the project was completed on time, whether any penalties/delay charges were applied, whether there were any contractual disputes and whether the company would use the services of your company again]
CLIENT CONTACT PERSON CONTACT PERSON DESIGNATION
TELEPHONE NO VALUE OF CONTRACT UNDERTAKEN
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2. INFORMATION FOR EMPOWER’S TECHNICAL/PROJECTS DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Projects Dept.)
BENCHMARK
SCORE (by
Empower)
5
5
5
5
5
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
ORGANIZATION, MANAGEMENT AND OPERATION EXPERIENCES
2.11. Consultant Corporate Profile, Commercial Profile, Quality Health Safety Environment Management, IT Facilities and Communications and Local Offices
(to be evaluated based on submissions)3
2.12. The Consultant is the main consultant for the Master Developer and completed at least one master development
(brief description and provide evidences)3
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2.13. The Consultant is aware of relevant local rules and regulations and can effectively manage and coordinate with statutory authorities for NOC and routine work on day-to-day basis.
(brief description and provide evidences)
3
2.14. The Consultant has previously worked as an infrastructure consultant
(brief description and provide evidences) 3
2.15. The Consultant has previously executed design, engineering, project management of district cooling plant projects
(brief description and provide evidences)3
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
2.16. The Consultant has previously executed district cooling chilled water pipe network projects
(brief description and provide evidences)3
2.17. The Consultant has executed any other design and supervision services
(brief description and provide evidences) 3
PROFESSIONAL STAFF QUALIFICATIONS AND COMPETITIVENESS
2.18. Management Team Staff (provide staff cv) 5
2.19. Design Team Staff (provide staff cv) 5
2.20. Supervision Team Staff (provide staff cv) 5
2.21. Admin Team Staff (provide staff cv) 5
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
TOTAL SCORE FOR SECTION 2 [INFORMATION FOR EMPOWER’S PROJECTS DEPARTMENT] 90
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
3. INFORMATION REQUIRED BY EMPOWER’S COMMERCIAL DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
3.1. Under which of which of the following methods of Consulting has your company undertaken Projects
(a) Supervision Only (With Client / Other Consultant Design) Yes No 5
(b) Design & Supervision (With own Design) Yes No 5
(c) Supervision with Partial Client / Other Consultant Design Yes No 5
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
3. INFORMATION REQUIRED BY EMPOWER’S COMMERCIAL DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
(d) Engineer, Procure and Supervision (Development of Client’s FEED) Yes No 5
3.2. Under which of the following forms of Contract has your company executed Projects [Please specify any other in the space provided]
FORM OF CONTRACT EDITION YEAR
(a) FIDIC CLIENT / CONSULTANT MODEL SERVICES AGREEMENT 3RD Edition 1998 5
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
3. INFORMATION REQUIRED BY EMPOWER’S COMMERCIAL DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
ANY OTHER FORMS OF CONTRACT
(b) (Please specify) Info Info
(c) (Please specify) Info Info
(d) (Please specify) Info Info
3.3. Please confirm your Company’s ability to obtain the following Insurances
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
3. INFORMATION REQUIRED BY EMPOWER’S COMMERCIAL DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
TYPE OF POLICY OBTAINED IN PAST ABILITY TO OBTAIN MAX LEVEL OF COVER THAT CAN BE PROVIDEDYES NO YES NO
(a) Professional Indemnity 4
(b) Consultant’s All Risk 4
(c) Third Party Liability 4
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
3. INFORMATION REQUIRED BY EMPOWER’S COMMERCIAL DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
(d) Employer’s Liability & Workmen’s Comp. 3
3.4. Please provide details of the last 5 insurance claims raised by your company
TYPE OF POLICY AGAINST WHICH CLAIM WAS MADE
AMOUNT OF CLAIM YEAR OF CLAIM CLAIM SETTLED BY INSURANCE COMPANY
No Yes 2
CONSULTANTPRE-QUALIFICATION FORM
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Owner COMMERCIAL DEPT
3. INFORMATION REQUIRED BY EMPOWER’S COMMERCIAL DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
No Yes 2
No Yes 2
No Yes 2
No Yes 2
3.5. Please provide information on the number of formal contractual disputes that your company 5
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
3. INFORMATION REQUIRED BY EMPOWER’S COMMERCIAL DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
has had in the previous 4 years [Provide numbers of disputes and the number that were settled successfully in your company’s favour]PERIOD COURT CASES ARBITRATION CASES SETTLED AMICABLY
NR OF CASES
NR. CASES SUCCESSFUL
NR OF CASES
NR. CASES SUCCESSFUL
NR OF CASES
NR. CASES SUCCESSFUL
(a) Most recent year
(b) Year 2
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
3. INFORMATION REQUIRED BY EMPOWER’S COMMERCIAL DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
(c) Year 3
(d) Year 4
3.8. List any contracts entered into by your company that have been suspended or terminated by your Clients in the last 5 years 5
PROJECT NAME CLIENT’S NAME SUSPENSION TERMINATION
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
3. INFORMATION REQUIRED BY EMPOWER’S COMMERCIAL DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
DEFAULT BY CONSULTANT
NON CONSULTANT
RELATED
DEFAULT BY CONSULTANT
CLIENT’S CONVENIENC
E
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
3. INFORMATION REQUIRED BY EMPOWER’S COMMERCIAL DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Commercial Dept.)
BENCHMARK
SCORE (by
Empower)
TOTAL SCORE FOR SECTION 3 [INFORMATION FOR EMPOWER’S COMMERCIAL DEPARTMENT] 60
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
4. INFORMATION REQUIRED FOR EMPOWER’S FINANCE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Finance Dept.)
BENCHMARK
SCORE(By
Empower)
4.1. No of Shares in Company 2
4.2. Value of Each Share 2
4.3. Paid-up Capital 2
4.4. Name of Principle Bank: 2
4.5. Account No: 2
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
4. INFORMATION REQUIRED FOR EMPOWER’S FINANCE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Finance Dept.)
BENCHMARK
SCORE(By
Empower)
4.6. Branch Name: 2
4.7. Branch Telephone No: 2
4.8. Please provide details of the value of facilities that your company holds with its bankers for providing bonds and bank securities and the balance of the facility available at the date of submitting this prequalification
10
BANK NAME BONDING FACILITIES HELD WITH BANKS BALANCE OF
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
4. INFORMATION REQUIRED FOR EMPOWER’S FINANCE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Finance Dept.)
BENCHMARK
SCORE(By
Empower)
FACILITY AT PQ DATE
Performance Bonds
Advance Payment Bonds
RetentionBonds
Total Bonding Facility
CONSULTANTPRE-QUALIFICATION FORM
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Revision # 4.3
Date 10-Nov-2019
Page 41 of 79
Owner COMMERCIAL DEPT
4. INFORMATION REQUIRED FOR EMPOWER’S FINANCE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Finance Dept.)
BENCHMARK
SCORE(By
Empower)
4.9. Do you have any arrangements with your Bankers whereby you are under obligations to directly assign Project payments to the Bank
No Yes (provide details below) 10
Bank Name: Info Info
Bank Name: Info Info
CONSULTANTPRE-QUALIFICATION FORM
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Revision # 4.3
Date 10-Nov-2019
Page 42 of 79
Owner COMMERCIAL DEPT
4. INFORMATION REQUIRED FOR EMPOWER’S FINANCE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Finance Dept.)
BENCHMARK
SCORE(By
Empower)
Bank Name: Info Info
4.12. Anticipated Company Turnover in Current Year: 2
4.13. Company Turnover in Last Financial Year: 2
4.14. Company Turnover in Previous Financial Year 2
CONSULTANTPRE-QUALIFICATION FORM
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Revision # 4.3
Date 10-Nov-2019
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Owner COMMERCIAL DEPT
4. INFORMATION REQUIRED FOR EMPOWER’S FINANCE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower Finance Dept.)
BENCHMARK
SCORE(By
Empower)
4.15. Declared Profit in Last Financial Year (if company is listed or a PJSC)
2 if applies
4.16. Declared Profit in Previous Financial Year (if company is listed or a PJSC)
2 if applies
TOTAL SCORE FOR SECTION 3 [INFORMATION FOR EMPOWER’S FINANCE DEPARTMENT] 405
CONSULTANTPRE-QUALIFICATION FORM
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Revision # 4.3
Date 10-Nov-2019
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Owner COMMERCIAL DEPT
5. INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
PART 1 - QUALITY
5.1. Does your Company have a signed Quality Policy Manual?
No Yes 5
Copy attached No Yes 5
5.2. Is your Company certified to ISO 9001 or equivalent?
No Yes 5
Copy attached No Yes 55 Change Bench mark score to 44 if Clauses 4.13 and 4.14 apply
CONSULTANTPRE-QUALIFICATION FORM
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Revision # 4.3
Date 10-Nov-2019
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Owner COMMERCIAL DEPT
5. INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
5.3. Do you have a copy of ISO9001:2008 certificate
No Yes 5
Copy attached No Yes 5
5.4. Do you have any objection to an on-site assessment by EMPOWER Personnel? No Yes 5
5.5. Has a QA Manager/Officer been appointed in your Company
No Yes [If YES, please provide name and reporting line] 5
CONSULTANTPRE-QUALIFICATION FORM
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Revision # 4.3
Date 10-Nov-2019
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Owner COMMERCIAL DEPT
5. INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
Name: 5
Reports To: 5
5.6. Do you perform your own Internal Quality Appraisal Audits?
No Yes [If YES, please provide information below] 5
Frequency of Audits 5
Date of last Audit 5
CONSULTANTPRE-QUALIFICATION FORM
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Revision # 4.3
Date 10-Nov-2019
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Owner COMMERCIAL DEPT
5. INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
(mm/yyyy)
Copy of latest Audit Report attached No Yes 5
SUB-TOTAL [PART 1 - QUALITY SECTION] 70
CONSULTANTPRE-QUALIFICATION FORM
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Date 10-Nov-2019
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Owner COMMERCIAL DEPT
INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
PART 2 – ENVIRONMENTAL
5.7. Is your Company certified to ISO 14000 (Environmental Management Systems)?
Yes 10
Copy of environmental manual & registration certificate attached
No yes 10
No
CONSULTANTPRE-QUALIFICATION FORM
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 49 of 79
Owner COMMERCIAL DEPT
INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
If NO manual & registration certificate briefly describe your environmental protection and waste management systems on a separate signed page.
10 if applies
5.8. How do you contribute for environmental protection?
10
CONSULTANTPRE-QUALIFICATION FORM
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 50 of 79
Owner COMMERCIAL DEPT
INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
[Attach a separate sheet with
CONSULTANTPRE-QUALIFICATION FORM
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 51 of 79
Owner COMMERCIAL DEPT
INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
SUB-TOTAL [PART 2 – ENVIRONMENTAL SECTION] 306
CONSULTANTPRE-QUALIFICATION FORM
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 52 of 79
Owner COMMERCIAL DEPT
INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
PART 3 – HEALTH AND SAFETY
5.11. Is your Company certified to OHSAS 18001 (Occupational Health & Safety Management System)?
[If YES attach copy of document describing core elements of your OHSAS & registration cert.]
Yes 5
Copy of document attached Yes No 5
OR[If NO, provide copy of your company’s occupational health & safety management system manual]
No 5
CONSULTANTPRE-QUALIFICATION FORM
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 53 of 79
Owner COMMERCIAL DEPT
INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
Copy of document attached Yes No 5
5.14. Does your Company maintain records of all accidents and injuries sustained?
[If YES, provide record of your safety performance over the last 3 years (number of Lost Time Injuries, Medical Treatment Cases, etc.)]
No Yes 5
Copy of document attached Yes No 5
5.17. Has a Safety Manager/Officer been No Yes [If YES, please provide name 56 Change Bench Mark score to 40 if Clause 5.7 applies
CONSULTANTPRE-QUALIFICATION FORM
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 54 of 79
Owner COMMERCIAL DEPT
INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
appointed in your Company?
and reporting line]
Name: 5
Reports To: Info Info
5.18. Do you have project specific QHSE Objectives & Targets/KPIs?
If YES, provide the reports for QHSE Objectives & Targets / KPIs (Planned Vs Actual
No Yes 5
CONSULTANTPRE-QUALIFICATION FORM
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 55 of 79
Owner COMMERCIAL DEPT
INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
achievement) for the projects executed by organization in
Copy of document attached Yes No 5
SUB-TOTAL [PART 3 – HEALTH & SAFETY] 100
CONSULTANTPRE-QUALIFICATION FORM
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 56 of 79
Owner COMMERCIAL DEPT
INFORMATION FOR EMPOWER QHSE DEPARTMENT
(Completion of all Sections is Mandatory) (Score to be filled by Empower QHSE Dept.)
BENCHMARK
SCORE (by
Empower)
TOTAL FOR QHSE PARTS 1, 2 & 3 200
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 57 of 79
Owner COMMERCIAL DEPT
CHECKLIST FOR DOCUMENTS TO BE ATTACHED [CONSULTANT TO TICK AS APPLICABLE]
NAME OF DOCUMENT ITEM REF. IN PQ DOCUMENT ATTACHED
Company Brochure Guidelines YES NO
UAE Commercial Licence 1.12 YES NO
Chamber of Commerce Registration Certificate 1.15 YES NO
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 58 of 79
Owner COMMERCIAL DEPT
CHECKLIST FOR DOCUMENTS TO BE ATTACHED [CONSULTANT TO TICK AS APPLICABLE]
NAME OF DOCUMENT ITEM REF. IN PQ DOCUMENT ATTACHED
VAT Registration Certificate 1.17 YES NO
Notarised & Attested Power of Attorney 1.23 YES NO
Written Client References 2.7 YES NO
Professional Staff CVs 2.15 – 2.18 YES NO
Audited Financial Reports last 3 years 4.13 YES NO
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 59 of 79
Owner COMMERCIAL DEPT
CHECKLIST FOR DOCUMENTS TO BE ATTACHED [CONSULTANT TO TICK AS APPLICABLE]
NAME OF DOCUMENT ITEM REF. IN PQ DOCUMENT ATTACHED
Signed Quality Policy manual 5.1 YES NO
ISO 9001 Certificate & ISO 9001:2008 Certificate 5.2 - 5.3 YES NO
Latest Internal Quality Audit Report 5.6 YES NO
Environmental Manual & Registration Certificate 5.7 YES NO
OHSAS 18001 Certificate and Manual 5.9 YES NO
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 60 of 79
Owner COMMERCIAL DEPT
CHECKLIST FOR DOCUMENTS TO BE ATTACHED [CONSULTANT TO TICK AS APPLICABLE]
NAME OF DOCUMENT ITEM REF. IN PQ DOCUMENT ATTACHED
Accident & Injury Records 5.10 YES NO
QHSE KPI’s 5.12 YES NO
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 61 of 79
Owner COMMERCIAL DEPT
DECLARATION BY CONSULTANT
We confirm that the particulars given in this form are factual and correct and have been provided by an authorised representative of the Company. We authorise and accept that Empower may verify any such statements and other information in this questionnaire and further agree to furnish any additional information that may be required.Our Company agrees to be bound by the Laws of Dubai and the UAE current at the time of entering into any agreement/contract with Empower. We undertake to keep confidential all details and information relating to all transactions between Empower and the Company and shall not disclose any such information without the express written permission of an authorised representative of Empower. We also undertake to comply with the Government of Dubai’s Internal Security Regulations (ISR)
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 62 of 79
Owner COMMERCIAL DEPT
Signature:
Name of Authorised Representative:
Title of Authorised Representative
Date:
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 63 of 79
Owner COMMERCIAL DEPT
Company Stamp
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 64 of 79
Owner COMMERCIAL DEPT
FOR INTERNAL USE BY EMPOWERA. EMPOWER INTERNAL ASSESSMENT OF SECTION 1 – COMPANY DATA
BENCH MARK SCORE ACHIEVED SCORE PERCENTAGE SCORE APPROVED REJECTED
N.A. N.A. N.A.
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 65 of 79
Owner COMMERCIAL DEPT
Comments:
REVIEWING DEPARTMENTS’ APPROVAL / REJECTION
DESIGNATION SIGNATURE NAME DATE
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 66 of 79
Owner COMMERCIAL DEPT
Senior Commercial Officer
Director – Commercial
B. EMPOWER INTERNAL ASSESSMENT OF SECTION 2 – INFORMATION FOR EMPOWER PROJECTS/TECHNICAL DEPARTMENT
BENCH MARK SCORE ACHIEVED SCORE PERCENTAGE SCORE APPROVED REJECTED
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 67 of 79
Owner COMMERCIAL DEPT
Comments:
REVIEWING DEPARTMENTS’ APPROVAL / REJECTION
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 68 of 79
Owner COMMERCIAL DEPT
DESIGNATION SIGNATURE NAME DATE
Technical Executive
Head of Technical Department
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 69 of 79
Owner COMMERCIAL DEPT
C. EMPOWER INTERNAL ASSESSMENT OF SECTION 3 – INFORMATION FOR EMPOWER COMMERCIAL DEPARTMENT
BENCH MARK SCORE ACHIEVED SCORE PERCENTAGE SCORE APPROVED REJECTED
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 70 of 79
Owner COMMERCIAL DEPT
Comments:
REVIEWING DEPARTMENTS’ APPROVAL / REJECTION
DESIGNATION SIGNATURE NAME DATE
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 71 of 79
Owner COMMERCIAL DEPT
Senior Commercial Officer
Director – Commercial
D. EMPOWER INTERNAL ASSESSMENT OF SECTION 4 – INFORMATION FOR EMPOWER FINANCE DEPARTMENT
BENCH MARK SCORE ACHIEVED SCORE PERCENTAGE SCORE APPROVED REJECTED
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 72 of 79
Owner COMMERCIAL DEPT
Comments:
REVIEWING DEPARTMENTS’ APPROVAL / REJECTION
DESIGNATION SIGNATURE NAME DATE
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 73 of 79
Owner COMMERCIAL DEPT
Manager – Payables & Fixed Assets
Director – Finance
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 74 of 79
Owner COMMERCIAL DEPT
E. EMPOWER INTERNAL ASSESSMENT OF SECTION 5 – INFORMATION FOR EMPOWER’S QHSE DEPARTMENT
BENCH MARK SCORE ACHIEVED SCORE PERCENTAGE SCORE APPROVED REJECTED
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 75 of 79
Owner COMMERCIAL DEPT
Comments:
REVIEWING DEPARTMENTS’ APPROVAL / REJECTION
DESIGNATION SIGNATURE NAME DATE
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 76 of 79
Owner COMMERCIAL DEPT
Senior Quality Executive
OVERALL SUMMARYSECTION BENCHMARK
SCOREACHIEVED
SCORE%
SCOREDAPPROVED REJECTED
SECTION 1 – COMPANY DATA
SECTION 2- INFORMATION FOR TECHNICAL DEPT.
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 77 of 79
Owner COMMERCIAL DEPT
SECTION 3 – INFORMATION FOR COMMERCIAL DEPT.
SECTION 4 – INFORMATION FOR FINANCE DEPT.
SECTION 5 – INFORMATION FOR QHSE DEPT.
TOTAL SCORES
EMPOWER MANAGEMENT APPROVAL7
DESIGNATION SIGNATURE NAME DATE
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 78 of 79
Owner COMMERCIAL DEPT
CHIEF COMMERCIAL OFFICER
HEAD OF PROJECTS/TECHNICAL
CHIEF FINANCE OFFICER
Commercial Department
CONTRACTOR
Doc. # CD-FRM-009B
Revision # 4.3
Date 10-Nov-2019
Page 79 of 79
Owner COMMERCIAL DEPT
7APPROVAL IF GIVEN, SHALL BE VALID FOR 3 YEARS FROM THE LATEST DATE OF APPROVAL REFLECTED ABOVE
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