World Vision Development Foundation Inc.

-
Western Leyte

Standard
Prequalification
Form
for Contractors

Contractor: _________________________________________________________________________________

World Vision Development Foundation, Inc.

Western Leyte Sector
Anika Leasing Building (Former Stars & Stripes Grocery)
Purok Waling-Waling, Brgy. Punta, Ormoc City
6541 Leyte

Project: REPAIR/ REHABILITATION OF HEALTH CENTERS/ STATIONS

Date:

Notes to Applicants
Standard Pre-Qualification Evaluation Form for Contractors
________________________________________________________________________________________________

Project: REPAIR/REHABILITATION OF HEALTH CENTERS/STATIONS

1 Please answer all questions to the best of your knowledge.

2 Supplementary pages may be enclosed if required.
3 Please retain a copy of your proposal.
4 If a joint stock company is proposed, all companies are to respond to all questions.

Standard pages

A Title page G Resources: personnel 1

B Notes H Resources: personnel 2
C Structure and organisation 1 I Resources: plant
D Structure and organisation 2 J Reference list/experience in reconstruction
E Financial statement
F Joint Venture

Please list any additional pages enclosed with standard pages below:

1.

Structure and Organisation 1

WV-Western
Leyte
Standard Pre-Qualification Evaluation Form for Contractors
________________________________________________________________________________________________

Project: REPAIR/REHABILITATION OF HEALTH CENTERS/STATIONS

1 Name of company:
Address:
Contact person:
Telephone number: Fax number:
Registered office address: E-mail:
Name of director:
_____________________________________________________________________________

2 Description of company (for example, General Civil Engineering Contractor/PCAB License):

_____________________________________________________________________________

3 Number of years of experience as a general contractor: - in own country:

- internationally:
_____________________________________________________________________________

4 Number of years of experience as a subcontractor: - in own country:

- internationally:
_____________________________________________________________________________

5 Names and addresses of associated companies which are to be involved in the project –
and the roles they are to perform- parent/subsidiary/other:

_____________________________________________________________________________

6 If the company is a subsidiary, what involvement, if any, will it have in the project?

_____________________________________________________________________________
7 Company’s registration number (complete sheets 1-8):

Structure and Organisation 2

WV-Western
Leyte
Standard Pre-Qualification Evaluation Form for Contractors
________________________________________________________________________________________________

Project: REPAIR/REHABILITATION OF HEALTH CENTERS/STATIONS

8 Please indicate here or enclose an organisation chart showing the company structure
including the names and positions of director and key personnel, if relevant.

Financial Report

WV-Western
Leyte
Standard Pre-Qualification Evaluation Form for Contractors
________________________________________________________________________________________________

Project: REPAIR/REHABILITATION OF HEALTH CENTERS/STATIONS

1 Capital:
Authorised person:
Issued by:

2 Annual value of construction works undertaken for each of the last five years year (Please
indicate data of the implemented works of the last five years and the ones planned for the
current year).

Year

Home

Abroad

3 Description and Approximate value of current projects:

a. information regarding any litigation, current or during the last five years,
in which the firm(s) is involved, the parties concerned and disputed amount;

4 Please enclose copies of the company’s last three year’s accounts (profit/loss,
assets/liabilities):
a. Profit/loss statement
b. Balance sheet
c. Financial solvency
d. Last three years audited accounts

5 Please enclose the following does:

e. Bank account number of the company
f. Certification the company has fulfilled all their past and current obligations
concerning the payment of taxes from revenue authorities.
g. Evidence of adequacy of working capital for this contract, including access to
credit lines/availability of other financial resources.

Note: Only selected companies will be asked for the above mentioned
documents (listed in 4 and 5)

6
a. Does your company carry Public liability Insurance: yes no

Insurance company _______________, contact person ______________, Tel: __________

b. Does your company carry all Risk Insurance: yes no

Insurance company________________, contact person_______________, Tel.__________

c. Liquid assets
5

WV-Western
Leyte
Standard Pre-Qualification Evaluation Form for Contractors
________________________________________________________________________________________________

Project: REPAIR/REHABILITATION OF HEALTH CENTERS/STATIONS

Joint Venture

If the company intends to enter into a joint venture for the project, please give the
following information, otherwise state ‘’not applicable’’.

_____________________________________________________________________________

1 Names and addresses of joint venture partners:

_____________________________________________________________________________

2 Name of company leading the joint venture:

_____________________________________________________________________________

3 Name and address of banker of the joint venture:

4 Copy of the Joint Venture Agreement

Resources: Personnel 1

1 Number of staff: Technical: Administrative:

WV-Western
Leyte
Standard Pre-Qualification Evaluation Form for Contractors
________________________________________________________________________________________________

Project: REPAIR/REHABILITATION OF HEALTH CENTERS/STATIONS

_____________________________________________________________________________

2 Please list current executive directors:

Name: Current position: Years of experience with the

Company/in construction:

Resources: Personnel 2

List of information about other key personnel below:

_____________________________________________________________________________

WV-Western
Leyte
Standard Pre-Qualification Evaluation Form for Contractors
________________________________________________________________________________________________

Project: REPAIR/REHABILITATION OF HEALTH CENTERS/STATIONS

Name: Current position:

Years of experience: - with the company:
- in construction:

Major works for which responsible (type and value):

Fluency in English language:

_______________________________________________________________________________________________

Name: Present position:

Years of experience: - with the company:
- in construction:

Major works for which responsible (type and value):

Fluency in English Language:

_______________________________________________________________________________________________

Name: Present position:

Years of experience: - with the company:
- in construction:

Major responsibilities (type and value):

Fluency in English language:

_______________________________________________________________________________________________
Resources: Contractor’s Equipment and Facilities

Please indicate the equipment and facilities owned and leased by the company.

Type of Model Year of

equipment manufacturer manufacture Own equipment Leased equipment

WV-Western
Leyte
Standard Pre-Qualification Evaluation Form for Contractors
________________________________________________________________________________________________

Project: REPAIR/REHABILITATION OF HEALTH CENTERS/STATIONS

Other
Facilities:
owned
leased

Project History list

WV-Western
Leyte
Standard Pre-Qualification Evaluation Form for Contractors
________________________________________________________________________________________________

Project: REPAIR/REHABILITATION OF HEALTH CENTERS/STATIONS

Building address Construction/ Contract Value Year Contact person and tel. #
Reconstruction complet
ed

10

WV-Western
Leyte