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[{"$nulls":10},"LOGISTICS"]
[{"$nulls":10},"PRO-03.2"]
[{"$nulls":10},"Version 01/2022"]
[{"$nulls":4},"SUPPLIER'S QUESTIONNAIRE"]
["PART I: INFORMATION"]
["A. Company Details and General Information"]
["Name of Company",{"$nulls":5},"Trading As"]
["Address (headquarters)",{"$nulls":5},"Telephone"]
["Zip Code (headquarters)",{"$nulls":5},"Fax"]
["City (headquarters)",{"$nulls":5},"E-mail address 1"]
["PO Box",{"$nulls":5},"E-mail address 2"]
["Country (headquarters)",{"$nulls":5},"Website address"]
["Parent Company or name of owner",{"$nulls":5},"Subsidiaries/ Associates/ Overseas Representative"]
["Sales Person's Name",{"$nulls":5},"Sales Person's Position"]
["Sales Person's phone",{"$nulls":5},"Sales Persons' E-mail"]
["Management of the company: CEO, Executive Director, Deputy Director, President or Vice-President"]
["Name (as in passport or other government-issued photo ID)",{"$nulls":5},"Date of birth (mm/dd/yyyy)"]
["Government-issued photo Identification Document (ID) number",{"$nulls":5},"Type of ID "]
["ID country of issuance",{"$nulls":5},"Rank or title in organization"]
["Other names used (nicknames or pseudonyms not listed as “Name”)      ",{"$nulls":5},"Gender (e.g. male, female)"]
["Current employer and job title",{"$nulls":5},"Occupation"]
["Address of residence",{"$nulls":5},"Citizenship(s)"]
["Province/Region",{"$nulls":5},"E-mail addresses"]
["Is the individual a U.S. citizen or legal permanent resident?",{"$nulls":5},"Professional Licenses – State Issued Certifications"]
["Company's staff & insurance"]
["No. Full Time Employees",{"$nulls":5},"Employee average work wage per hour"]
["% of Men to Women",{"$nulls":5},"Any employee(s) with relatives working with ACTED?"]
["Are children employed?",{"$nulls":5},"Is a legal minimum wage applied?"]
["Paid vacations are offered?",{"$nulls":5},"Are flexible working hours offered?"]
["Name of insurance company",{"$nulls":5},"Staff covered by health issurance?"]
["Description of the Company"]
["Type of Business (multiple choices possible)"]
[]
["Sector of Business (multiple choices possible)"]
["Year Established",{"$nulls":5},"Country of registration"]
["Licence number",{"$nulls":5},"Valid until"]
["Working languages"]
[]
["Technical documents available in"]
[]
["B. Financial Information"]
["VAT Number",{"$nulls":5},"Tax Number"]
["Bank Name",{"$nulls":5},"Bank Account Number"]
["Bank Address",{"$nulls":5},"Account Name"]
["Swift/BIC number",{"$nulls":5},"Standard Payment Terms"]
["Has the company been audited in the last 3 years?"]
["Please attach a copy of the company's most recent Annual or Audited Financial Report"]
["Annual Value of Total Sales for the last 3 Years:"]
[null,"Year:","USD:",null,"Year:",null,"USD:","Year:","USD:"]
["Annual Value of Export Sales for the last 3 years"]
[null,"Year:","USD:",null,"Year:",null,"USD:","Year:","USD:"]
["C. Experience"]
["Companie's recent business with ACTED and/or other International Non Governmental organisation or United Nations Agencies:"]
[null,"Organisation","Contact person ",null,"Phone/E-mail",null,"Goods/Works/Services","Value (USD)","Year","Destination"]
[1]
[2]
[3]
[4]
[5]
[]
["What is your company's main area of expertise?"]
["What is your company's business coverage area?"]
["To which countries has your company exported and/or managed projects in the last 3 years?"]
["Provide any other information that demonstrates your company's qualifications and experience (eg. awards)"]
["List any national or international Trade/Professional Organisations of which your company is a member"]
["D. Technical Capability "]
["Type of Quality Assurance Certificate"]
["Type of Certification/Qualification Documents"]
["International Offices/Representation"]
["List below up to 10 of the core Goods and/or Services your company sells:"]
["1)",{"$nulls":4},"6)"]
["2)",{"$nulls":4},"7)"]
["3)",{"$nulls":4},"8)"]
["4)",{"$nulls":4},"9)"]
["5)",{"$nulls":4},"10)"]
["List the main assets of your company (trucks & heavy machines, heavy & valuable equipment, premises & warehouses, production sites etc.)"]
["1)",{"$nulls":4},"6)"]
["2)",{"$nulls":4},"7)"]
["3)",{"$nulls":4},"8)"]
["4)",{"$nulls":4},"9)"]
["5)",{"$nulls":4},"10)"]
["E. Miscellaneous"]
["Does your company have an Environmental Policy?"]
["Does your company have an Ethical Trading Policy?"]
["Does your company have an Anti-terrorist Policy?"]
["Is your company compliant with the EU General Data Protection Regulation (or equivalent)?"]
["If you answered yes to the above two questions, please attach copies of your policy:"]
["Has your company ever been bankrupt, or is in the process of being wound up, having its affairs administered by the courts, has entered into an arrangement with creditors, has suspended business activities, is the subject of proceedings concerning these matters, or is in any analogous situation arising from a similar procedure provided for in national law?"]
["If you answered yes, please provide details:"]
["Has your company ever been convicted of an offence concerning its professional conduct by a judgment which has force of res judicata?"]
["If you answered yes, please provide details:"]
["Has your company ever been guilty of grave professional misconduct proven by other means? "]
["If you answered yes, please provide details:"]
["Has your company ever not fulfilled its obligations relating to the payment of social security contributions, or the payment of taxes in accordance with the law of the country in which it is established, or with those of France, or those of the country where the contract is to be performed?"]
["If you answered yes, please provide details:"]
["Has your company ever been the subject of a judgement which has the force of res judicata for fraud, corruption, involvment in a criminal organisation or any other illegal activity?"]
["If you answered yes, please provide details:"]
["Has your company ever been declared to be in serious breach of contract for failure to comply with its contractual obligations, following another procurement procedure or grant award procedure financed by a donor country?"]
["If you answered yes, please provide details:"]
["Has your company ever been declared to be in serious breach of contract for failure to comply with its contractual obligations, following another procurement procedure or grant award procedure financed by a donor country?"]
["If you answered yes, please provide details:"]
["Has your company ever been in any dispute with any Governement Agency, the United Nations, or International Aid Organisations (including ACTED)?"]
["If you answered yes, please provide details:"]
["Do you agree with terms of payment of 30 days?",{"$nulls":5},"Do you accept visit of ACTED staff & external auditors to your office?"]
[]
["PART II: CERTIFICATION"]
["I, the undersigned warrant that the information provided in this form is correct, and in the event of changes, details will be provided to ACTED as soon as possible in writing. I also understand that ACTED does not do business with companies, or any affiliates or subsidiaries, which engage in any practices that are in breach of ACTED policies for Child Protection, Conflict of Interest Prevention, Anti-fraud & Anti-Corruption, Anti-terrorism & Anti-Money Laundering, Data Protection, against Sexual Exploitation, and for Environmental Safeguarding."]
["(available on https://www.acted.org/en/about-us/values-and-policies/code-of-conduct-and-policies/ and on request at any ACTED office)."]
["Name:",{"$nulls":5},"Date:"]
["Title/Position",{"$nulls":5},"Place:"]
["E-mail address (for contact for verification purposes):",{"$nulls":5},"Signature:"]
["Phone number (for contact for verification purposes):",{"$nulls":5},"Company Stamp:"]
[]
["Check list of supporting documents ",{"$nulls":6},"For ACTED use only"]
["1)","Trading license"]
["2)","VAT registration/tax clearance certificate"]
["3)","Company profile"]
["4)","Proof of trading/dealership/agent"]
["5)","Evidence of similar contracts"]
["6)","References"]
["7)","Particulars of CEO and key personnel"]
["8)","Articles of Association & Certificate of incorporation"]
["9)","Financial statements (latest)"]
["10)","Other (specify): "]
[]
["PART III: ASSESSMENT (ACTED use only)"]
["Assessors"]
["Name & Title of Assessing ACTED Staff:"]
["1) ",{"$nulls":4},"3) "]
["2) ",{"$nulls":4},"4) "]
["Findings of Vendor's assessment:"]
[]
[]
["Vendor's office/ warehouse / works site visited?",{"$nulls":6},"Date:"]
["Findings of Site Visit / Works Visit / Consultation with References:"]
[]
[]
["Decision"]
[{"$nulls":5},"Reason:",null,null,"Date:"]
[]
["By signing this supplier assessment, I hereby testify that:\n - I do not have any conflict of interest with any of the suppliers listed in the present document (as per ACTED Conflict of Interest Prevention policy)\n - I have not taken part into any fraudulent nor corruptive practice for the present procurement (as per ACTED Anti-Fraud & Corruption policy)"]
["Area Logistics Manager's /\nCountry Logistics Manager's Name:",{"$nulls":5},"Signature:"]