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United Nations Children’s Fund
Baghdad, Iraq
Telephone +39083 105 3774 / +39083 105 3724
Mobile +964 7809126785 (Zain)
E-mail:
www.unicef.org / منظمة الأمم المتحدة للطفولـة
بغـداد، العراق
هاتف390831053724+ / 390831053774 +
نقـال +964 7809126785 (زين)
بريد الكتروني: g
www.unicef.org

Supplier /Contractor Profile Form (For UNICEF Iraq)

UNICEF fully subscribes to the Convention on the Right of the Child and draws the attention of potential suppliers / contractors to Article 32 of the Convention which inter alia requires that a child shall be protected performing any work that is likely to be hazardous or to interfere with the Child’s education or to be harmful to the Child’s health or physical, mental, spiritual, moral or social development.
UNICEF reserves the right to terminate any contract unconditionally and without liability in the event that the supplier / contractor are discovered to be in non-compliance with the national labour laws and regulations with respect to child employment.
The supplier / contractor guarantees that neither the supplier’s / contractor’s company nor any of its affiliates, nor any subsidiaries controlled by the supplier’s / contractor’s company is engaged in the sale or manufacture of anti-personnel mines or of components utilized in the manufacture of anti-personnel mines. The supplier / contractor recognize that a breach of this provision will entitle UNICEF to terminate contract with the supplier / contractor.

I representing the company acknowledge and ensure the company’s compliance with the above statement. By signing this form, I also confirm that any offer of compensation to any UNICEF staff person, no matter how small or in what form, may result in temporary or permanent exclusion from doing future business with UNICEF.

Company Name: ______Date: ______

Name ______Signature: ______

Title: ______Company Stamp

For UNICEF Official use only:

Date Visited: ______by: ______

No. Assigned (ProMS):______

·  The following part should be completed by supplier / contractor and submitted to UNICEF in duplicate.

·  Any information is for UNICEF official use only and will be treated as confidential.

·  Attach additional document(s), if space is not enough, but information must be provided in the following sequence for all columns.

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1. Present Company’s Name: ______

1-1. Previous Name of Company (if applicable): ______

(Please attach relevant document)

1-2. Parent Company’s Name (if applicable): ______

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2. Address (Street): ______

(Town): ______(Governorate): ______

Postal Address (P.O. Box): ______

2-1. Please attach a sketch shown the location of your office

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3. Telephone / Cell Number: ______

4. Fax Number: ______

5. E-mail: ______

6. Website: ______

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7. Contact Person (minimum 2 persons)

7-1. Name: ______Title (official capacity): ______

Signature: ______

7-2. Name: ______Title (official capacity): ______

Signature: ______

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7-3. Name of Person authorized to collect cheque from UNICEF for payment:

Name: ______Title (official capacity): ______

Specimen Signature: ______Specimen Signature: ______

8. Type of Organization (only one is allowed to select and mark X)

State Enterprise: _____ Private Company: _____ other (Please specify): ______

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9. Activity Category (it is applicable please mark more than one X)

Manufacture: ___ Authorized Agent: ___ Trading Company: ___ Construction Company: ___

General Contractor: ___ Product of Raw Materials: ___ Transportation Company:___

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10. Please indicate the main services / products, you are interested in providing to UNICEF (briefly)
(Please provide product list or catalogue)

11. Please specify previous contracts in attached Annex A.

12. If agent, trading house, do you hold sole / exclusive right / license? Yes / No

13. Does your company hold Membership of National / International Professional Association? Yes / No

(If yes, please attach proof of membership.)

14. Please list Governorate in Iraq where you are interested in working with UNICEF:

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15. Supporting Documentation for registration / establishment (Only if applicable, also please attach a copy of documents.)

15-1. MOFA Approval Letter (the latest) Ref No. ______Date of Issue: ______

15-2. Registration with Ministry of Trade Ref No.______Date of Issue: ______

15-3. Baghdad Chambers of Commerce ID No.______Date of Issue: ______

Business Field according to the ID:______

15-4. Civil Engineering Grade / Classification (Ministry of Planning): ______

15-5. Electrical – Mechanical Engineering Grade / Classification (Ministry of Planning): ______

15-6. Date of Expiry of Lease Contract for Office Premise(s)

(Please attach a copy of the contract endorsed by Notary Public)

15-7. Date of Establishment: ______

(Please attach documents, e.g. Minutes of the First Meeting of Board of Director)

15-8. Registration with Engineering Union: ____

16. Resources

16-1. Number of full time employees: _____ (Please complete Annex B)

16-2. Company Property / Asset total value: USD $______

(Please complete Annex C)

17. Storage / Warehouse Capacity: ______M3 (Roofed Area ______M3) (Open Space _____ M3)

18. Maximum ceiling of a contract value, which company can work: USD $______

19. Gross Annual Turnover: Current year estimate: USD $______

Last year USD $______

Year before USD $______

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20. Bank Name: ______

20-1. Bank Address (City & Country)______

20-2. Bank Account No. ______

20-3. Account Holder: ______

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21. Approved Standard (ISO, FDA, GMP etc. please specify :______)

22-1. Does your company have a statement on quality policy? Yes / No (If yes, please attach a copy.)

22-2.Which of the flowing doe your company implement?

Raw Material Control: ____ Sub-Component Control: ____

Process Control: ____ Final/Pre-delivery Control: ____

22-3. Authorized Contact Person regarding Quality Control:

Name: ______Title: ______

Telephone: ______E-Mail: ______

23. Is your company covered by any third party liability insurance? Yes / No

(If yes, please provide copy of relevant document,)

24. Does your company have a documented environmental policy? Yes / No

(If yes, please provide copy of relevant document,)

I hereby certify that the information provide above and in all the Annexes are correct and that no person in any connection with this establishment as a principal or employee, so far as know, it employed by UNCIEF, or barred by UNICEF, as a suppler / contractor for providing supplies / services.

Name ______Signature: ______Date: ______

Title: ______Company Stamp