SUPPLIER PROFILE FORM

All pages to be completed by Supplier and submitted to UNICEF.

Requested information is for UNICEF's internal use only and will be treated as confidential.

UNICEF fully subscribes to the Convention on the Rights of the Child and draws the attention of potential suppliers to Article 32 of the Convention which inter alia requires that a child shall be protected from 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 is discovered to be in non-compliance with the national labour laws and regulations with respect to child employment.
The supplier guarantees that neither the supplier's company, nor any of its affiliates, nor any subsidiaries controlled by the supplier's company, is engaged in the sale or manufacture of anti-personnel mines or of components utilised in the manufacture of anti-personnel mines. The supplier recognises that a breach of this provision will entitle UNICEF to terminate its contract with the supplier.
I, representing the company, acknowledge and ensure the Company's compliance with the above statements. By signing this form I also confirm that I understand 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.
Organisation: ______
Name and Title: ______
Signature: ______
Date: ______

(please TYPE or PRINT)
(attach additional pages if space in columns is not enough but information must be provided in the following sequence for all columns) :
Section 1: General Information (if available please provide all documentation in English)

  1. Name of Company ______
  2. Parent Company (if applicable)______
2. Full Address:
______
______
______
______
______
______
3. Telephone (incl. country and area codes)______
4. Fax (incl. country and area codes) ______
4.1E-mail address ______
4.2www Home Page (if any) ______
5. Contact Person (name & title) ______
6. Type of Organization (one X only): State Enterprise ______
Private Company ______
Other (specify) ______
  1. Active Category (one X only)
Manufacturer: ____ Authorized Agent: ____
Trading Company: ____ Name of Principals: ____
Consultants: ____ Forwarder: ____
Other (Please Specify) ______
  1. If Agent/Trading House, do you hold sole/exclusive rights/license?
(please circle as applicable) Y / N (if Yes, please list on attachment)
  1. If US-based dealer, are you a "GSA" dealer?
(if Yes, please attach certificate)
10. Year Established ______
11. Number of Full Time Employees ______

Section 2: Financial Statement

12. Registration/Incorporation (please provide Incorporation Certificate and Certificate of Name Change, if applicable) Number ______
13. Bank Name and Address 14. Bank Account Number
______
______15. Bank Branch(Swift) Code
______
______16. VAT Number
______
  1. Payment Terms: ______
18. Audited Financial Statement Y / N (please circle correctly)
(Please attach a copy of your latest Audited Financial Statement. If not
available, please provide a certified copy of your income tax return

Section 3: Activities

19. Gross Annual Turnover: Current Year Estimate (GEL______)
Last Year (GEL ______)
Previous Year (GEL ______)
20. Annual Export Turnover: Current Year Estimate (GEL ______)
Last Year (GEL ______)
Previous Year (GEL ______)
  1. Previous Contracts (during the last two years) with United
Nations/Institutional or Governmental Organizations/Private Companies, for
above products/services.
Contract Reference Number: ______
(provide at least three references)
Date Value Product Destination Organization Name/Address
(a) ______
(b) ______
(c) ______
  1. Main products/services offered:
(Please provide Product List or Catalogue)
  1. Storage/Warehousing Capacity (in square meters) ______
24. Local Representation: (Please attach list of countries where your
local representative will provide warranty services on products / services
purchased from you - provide complete addresses of your subsidiaries /
agents, where applicable).

Section 4: Other Information

  1. Person(s) legally empowered to represent the Company:
Name Official Title
______
______
______
26. Approved Standards (ISO, FDA, GMP, etc): ______
(Please attach a copy of the Certificate(s)
27. Should your company have a Quality Assurance Policy, indicate
person(s) responsible together with title and telephone number:
______
  1. Membership of National/International Associations
(circle as applicable) Y / N (if Yes, please enclose list of names)
29. Third Party Liability (please provide copy of relevant document)
30. Patent infringement pending lawsuit Y / N (if Yes, please attach copy)
  1. Does your company have a written statement of its environmental
policy?
(circle as applicable) Y / N (if Yes, please attach copy)
32. Documents available in English ? Y / N
33. Any other information
(circle as applicable) Y / N (if Yes, please attach copies)

I hereby certify that the information provided above and in all the annexes iscorrect and that no person in any connection with this establishment, as a supplier for providing material, supplies or services, or as a principal or employee, is employed by UNICEF, or barred by UNICEF.

Name: ______
Title: ______/ Date: ______
Signature: ______