Vendor Registration for the supply of stores for Insurance Medical Services department 1. Name of firm : 2. a) Postal address of Head Office : b) Telephone No. : c) E-Mail ID : d) Fax No. : 3. Address of Branches / Distributors : 4. Whether firm has Regd.Office / branch : Yes / No office in Hyderabad/ Other States If yes, the following particulars may be furnished. a) Postal Address of Office in Hyderabad : b) Telephone no. : c) E-Mail ID : d) Fax No. : e) Registration certificate of the vendor : THE FIRM MAY PLEASE NOTE THAT DOCUMENTARY PROOF FOR REPLIES MARKED AS "YES" ARE MANDATORY. WHERE EVER, THERE IS NO DOCUMENTARY PROOF, THE REPLY WILL BE TAKEN AS "NO". 8. The following documents are to be enclosed. a) Experience details which includes certification from the various Government/ Non - Government organizations where similar nature of the works were carried out. b) The authorities of the Directorate of Insurance Medical Services reserves the right to inspect the developed web site of the other Government / Non- Government sectors basing on the documentary experience details furnished. c) The annual turn over for the past 2 years. d) Service tax/ VAT registration and latest tax clearance certificate. e) Audited financial statement for the last three financial years either by the distributor or by the manufacturer. f) Documentary evidence for the constitution of the organization indicating details of the name, address, telephone no. Fax. No. Email address of the firm and of the managing director/ partner/ proprietors. I / we ............do hereby declare that the entries made in this application form are true to the best of my/ our knowledge and also that we shall be bound by the acts of my / our duly constituted attorney. I/ we .............do hereby declare that no punitive action taken/ contemplated against my/ our firm by any central Govt. Institution/ State Govt.Institution I / we .............do hereby confirm that all future changes in the constitution or working of the firm, affecting the accuracy of the information now given would be promptly Signature.......... (Designation of person signing the Application form ( Proprietor, Partner, Manager etc) Place........................ Dated
