Appendix 1. Application for Registration 2. Letter of Application for Bidding 3. Tax evasion pledge 4. Manufacturer’s Authorization 5. Letter of Technical Support 6. Curriculum Vitae 7. Certificate of Employment 8. Specification of Equipment <Refer to MS Excel Document> 9. List of Documents to be Submitted (SEALED ENVELOPE) 9-1. Application for Eligibility Examination 9-2. Self-evaluation for Eligibility Examination and Examination Table 9-3. Detailed Scores by Item 10. Bid Price Proposal <Refer to MS Excel Document> (SEALED ENVELOPE) 11. Building Layout <Refer to PDF Document> 12. Financial Accounting Report 13. Supply Plan (For Successful Bidder)
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Appendix
1. Application for Registration
2. Letter of Application for Bidding
3. Tax evasion pledge
4. Manufacturer’s Authorization
5. Letter of Technical Support
6. Curriculum Vitae
7. Certificate of Employment
8. Specification of Equipment <Refer to MS Excel Document>
9. List of Documents to be Submitted (SEALED ENVELOPE)
9-1. Application for Eligibility Examination
9-2. Self-evaluation for Eligibility Examination and Examination Table
9-3. Detailed Scores by Item
10. Bid Price Proposal <Refer to MS Excel Document> (SEALED ENVELOPE)
11. Building Layout <Refer to PDF Document>
12. Financial Accounting Report
13. Supply Plan (For Successful Bidder)
[Appendix 1 Application for Registration]
Application for Registration
To: President of KOICA KOICA Reg. No.
Name of Firm Taxpayer ID No.
Name of
CEO
ID No. of
Chief Executive
E-mail Homepage
Address of FirmTel. No.
Fax No.
Type of FirmPrivate Firm/
Corporation
Country in which Firm is
registered
Date of
Incorporation
Capital of FirmNumber of
Employees
Sales Records for past 3 years
Persons authorized
to sign Bids &
Contracts
Job Title Name Signature or Seal
Products
to be offered
Products Classification CodeSales Records
for past 3 years
Required
Documents ◦ Certificate of Taxpayer`s ID No. or Office Ownership
I, as a legally authorized representative of the Firm, duly state that all of the above information is true and correct and hereby duly apply for registration.
※ 1. Documents to be submitted must be issued or authenticated by Government Agency or authority concerned of the Applicant`s country, otherwise these documents must be certified by the notary public.
2. This application form must be filled out in English. When the original documents are in a language other than English, they must be accompanied by a duly notarized English translation.
Name of CEO Date
Signature or Seal
Name & Title of Applicant
E-mail :
[Appendix 2 Letter of Application for Bidding]
Letter of Application for Bidding1. Bidding and Bid Security
Bid Title Provision of Medical Equipment for National Pediatric Hospital in Phnom Penh, Cambodia
Invitation No. KOICA 2016-0000
Date of Submission of biddingdocuments and bid price July,25th, 2016
Application for Bidding (Name of Company) alone
Bid Security
UD $ ※ A bid security of five percent (5%) of your bid amount (Period: at least 30 days from date of submission of bidding documents and bid price )
2. Details of the Bidder
Section Name of Firm Address
Chief ExecutiveBidding Agent
Name Taxpayer ID No.
Representative Company (Seal) Name (Sign)
We apply for participating in the above Bid in accordance with Bid Documents including Bid
Instructions under International Guideline and Instructions on the International Bidding for
Equipment Provision
If the successful bidder fails to enter into the contract within the prescribed period of time, the bid
security deposited by the bidder shall belong to KOICA.
Attachment 1. Bid Security 1 copy
2. bidding documents and bid price, etc. 1 copy respectively
Company Name:
Chief Executive: (Seal)
Date :
Bid Security
Invitation No : KOICA-2016-0000Project Works : Provision of Medical Equipment for National Pediatric Hospital in Phnom Penh, CambodiaDate of Bid:
We, the undersigned, hereby guarantee that, if awarded a contract, we will perform faithfully the requirements of the contract.
(i) Should we withdraw our bid before its expiration and/or after being awarded by the Korea International Cooperation Agency (KOICA), or(ii) Should we refuse to conclude the contract, or(iii) Should we fail to establish a Contract Deposit in accordance with the contractual conditions,
We undertake to pay KOICA immediately an amount equivalent to five (5) percent of the total bid price, according to, and upon receipt of, its first written demand, without KOICA having to substantiate its demand.
We further guarantee that we will not claim against or appeal to KOICA in relation to any unfavorable action which may be taken against us by KOICA on the grounds that we have not complied with the above conditions.
Signed on , 20yy
Contractor: by [ Signature ] Name: Title: Guarantor: by [ Signature ] Name: Title:
* A different form of security is acceptable to KOICA only when it is substantially equivalent to the form and substance of the security established by KOICA herein.
[Appendix 3 Tax evasion pledge]
Tax evasion pledge
1. We undertake full understanding and compliance of “Article 27-5 of ACT ON CONTRACTS TO
WHICH THE STATE IS A PARTY” and “Article 12 of the ENFORCEMENT DECREE OF
THE ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY“. We declare that neither
we nor any other party acting on our behalf with regard to the Project has engaged or will engage
in corrupt or fraudulent practices.
<Reference: Article 27-5 of ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY>
(Article 27-5) Restriction, etc. on Qualification for Participation of Inappropriate Business Entities in Tendering
Procedures
A person for whom there is a request by the Fair Trade Commission to restrict the qualification of participating
tendering, due to the violation of the Monopoly Regulation and Fair Trade Act or the Fair Transactions in
Subcontracting Ac
<Reference: Article 12 of ENFORCEMENT DECREE OF THE ACT ON CONTRACTS TO
WHICH THE STATE IS A PARTY>
(Article 12) Qualifications for Participation in Competitive Tendering Procedures
A person for whom there is a request by the Fair Trade Commission to restrict the qualification of participating
tendering, due to the violation of the Monopoly Regulation and Fair Trade Act or the Fair Transactions in
Subcontracting Act.
2 According to the above, we have to submit evidence in accordance with Article 2 (5) of the ACT
ON THE LAPSE OF CRIMINAL SENTENCES, however difficult it may be to do so. We hereby
confirm the following are not applicable.
PUNISHMENT OF TAX EVADERS ACT
Article 3 (Tax Evasion): A person who evades a tax of at least 500 million won.
CUSTOMS ACT
Article 270 (Offense, etc. of Evading Customs Duties): A person who has his/her custom duties imposed on personal goods that are reduced or exempted by any illegal means or that evades the collection of customs duties on goods for which customs duties have been reduced or exempted at least 500 million won.
FRAMEWORK ACT ON LOCAL TAXES
Article 129 (Evasion of Local Taxes): Any person who evades a local tax or obtains a refund or deduction thereof by deceit or other fraudulent means by at least 500 million won.
ADJUSTMENT OF INTERNATIONAL TAXES ACT
Article 34-2 (Penalty Provisions Applicable to Non-Fulfillment of Obligation to Report on Overseas Financial Accounts): Where a person is liable to report on information on his/her overseas financial account under Article 34 (1) fails to report within the reporting deadline, or under-reports the amount (hereafter referred to as "amount in violation of the liability to report" in this Chapter) exceeds five billion won.
FOREIGN EXCHANGE TRANSACTIONS ACT
Article 18 (Reporting, etc. on Capital Transactions): Any person who intends to perform capital transactions, and
Article 29 (Penalty Provisions): Any person whose amount from a violation of an obligation to report under Articles 16 or 18 has exceeded the amount prescribed by Presidential Decree within the extent of not less than five hundred million won
If the above statement is different from the fact, we confirm that we could receive sanction disposition as improper business in accordance with Article 76 of the "ENFORCEMENT DECREE OF THE ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY" and the termination of contract
Date:
Name: (sign)
[Appendix 4 Manufacturer’s Authorization]
Manufacturer’s Authorization
[The Bidder shall require the Manufacturer to fill in this Form in accordance with the instructions
indicated. This letter of authorization should be on the letterhead of the Manufacturer and should be
signed by a person with the proper authority to sign documents that are binding on the
Manufacturer]
Date: [insert date (as day, month and year) of Bid Submission]
To: [insert complete name of Purchaser]
WHEREAS
We [insert complete name of Manufacturer], who are official manufacturers of [insert type of goods
manufactured], having factories at [insert full address of Manufacturer’s factories], do hereby
authorize [insert complete name of Bidder] to submit a bid the purpose of which is to provide the
following Goods, manufactured by us [insert name and or brief description of the Goods], and to
subsequently negotiate and sign the Contract.
We hereby extend our full guarantee and warranty in accordance with Clause 18 of the General
Conditions of Contract, with respect to the Goods offered by the above firm.
Signed: [insert signature(s) of authorized representative(s) of the Manufacturer]
Name: [insert complete name(s) of authorized representative(s) of the Manufacturer]
Title: [insert title]
Duly authorized to sign this Authorization on behalf of: [insert complete name of Bidder]
Dated on day of , [insert date of signing]
[Appendix 5 Letter of Technical Support]
Letter of Technical Support
To: President of Korea International Cooperation Agency.
Project: Provision of Medical Equipment for National Pediatric Hospital in Phnom Penh,
Cambodia
We hereby commit that we, the company, will designate at least three(3) qualified staffs in project
site(National Pediatric Hospital in Phnom Penh, Cambodia) for technical support such as quickly
the demand of repair and replacement of the goods during the deflect repair period(for 2 years)
20 . . .
Address :
Company:
Representatives: (Seal)
[Appendix 6 Curriculum Vitae]
Curriculum Vitae
Full NameAddress:
Telephone: (Mobile) Email:
LANGAUGE SKILL(Sample)▪ Khmer : Native
▪ English : Good
EDUCATION AND TRAINING (Sample)▪ 1999: Certificate of high school
▪ 2004: Bachelor degree of Business Administration at National University of Management (NUM) in major
Management information system(MIS)
- Business English, Principle of Accounting, Principle of publish relation, Principle of management and Principle of
- KOICA will review and approve the submitted maintenance plan. If KOICA approve it, the
contractor will dispatch an engineer. KOICA will settle the costs after reviewing the
outcome report.
※ The cost of maintenance is considered to be included in the cost of bidding. If KOICA
asks for additional maintenance after the maintenance period has expired the
contractor can proceed through a separate agreement.
Maintenance is a separate concept from the defect repair(Including warranty).This includes tasks of support for technical support after delivery and installation, as
well as replacement of consumables for required repairs. Support is offered through the maintenance of the period.
6. Planning for local purchasing and installation (training)
○ According to RFP, please describe the local purchase and installation (and training)
plan. Including
- When and how to buy locally.
- Local Installation Schedule (Customs clearance and dispatch plan)
- Other RFP instructions (optional)
Prohibit submitting by modifying the default form without discussion and confirmation of KOICA
and PMC. Additional instructions can be added to the task.