Download Application For Enlistment As Contractor

ANNEXURE - I PUBLIC WORKS DEPARTMENT/ WATER RESOURCES DEPARTMENT, GOVERNMENT OF GOA APPLICATION FOR ENLISTMENT AS CONTRACTOR (The applicant should study the Rules of enlistment and the list of documents to be annexed with the application from before filling the form. Applications found deficient in any respect are liable to be rejected without any further correspondence.) CLASS ....... CATEGORY .......... 1. Name of applicant Shri/Mr./M/s. ..................... 2. Nationality Indian ...... .. Other............ 3. Address Regd. Office ............................ ............................ ............................ Head Office ............................ ............................ ............................ ............................ 4. Telephone Number .......... Fax No. ............ 5. Constitution Individual ....... Sole proprietorship concern.... . Partnership Firm.... .. Public Ltd. Company....... Private Ltd. Company .................. 6. If partnership firm, names of the partners/ if company name of Directors 1. ................. 2. ................ . 3. ................ . 4. ................ . 5. ................ . 6. ................ . 7. Is the individual/ sole proprietor/ any partner / Directors pf Company: (a) Dismissed Government Servant Yes.... . No....... (b) Removed from approved list of Contractors Yes.... . No....... (c) Demoted to a lower class of Contractors Yes.... . No....... (d) Having business banned/ suspended by any 8. (a) Name of person holding power of attorney (b) Nationality Indian ..... .. Other ... . © Liabilities 9. Name of Bankers with full address ........................ ........................ ........................ 10. Place of business ........................ 11. Full time technical staff in applicant's employ: (a) to (e) for Civil and Electrical, (f) for Furniture. (a) Graduate Engineers with minimum 5 years of experience Nos...... (b) Graduate Engineers with minimum 3 years of experience Nos... ... (excluding a above) (c) Graduate Engineers with minimum 3 years of experience Nos...... (excluding (a) and (b) above) (d) Graduate Engineers with minimum 3 years of experience Nos...... (e) Graduate Engineers with minimum 3 years of experience Nos.. .... (f) Furniture/Furnishing Designers Nos...... 12. Does the applicant have sufficient T&P Machinery, Equipment and workshop as per requirements mentioned In the Enlistment Rules for the class and category applied for (Attach details on a separate sheet) Yes... .. No... 13. Does the applicant possess valid Electrical Licence(For Electrical ) Yes ... . No... . 14. (a) Whether already enlisted with Goa PWD/WRD or any other Dept. Yes.. . No... (b) if yes, give details: (i) Name of department .................... (ii) Class and category .................... (iii) Enlistment authority and address ... ................. (iv) Enlistment No. and date .................... (v) Date of validity .................... (vi) Tendering limit .................... 15. Is any person working with the applicant is a near relative of the officer/official of Goa 17. Certificates from clients in original as per porforma given in Annexure IV for all eligible works. 18. Certificates: (i) I/We (including all partners) certify that I/We have read the Rules of Enlistment of Contractors in Goa PWD/WRD as amended up to-date and shall abide by them. (ii) I/We certify that I/we will not get myself/ourselves registered as Contractor(s) in the Department for more than one name. (iii) I/We certify that the information given above is true to the best of my/our knowledge. I/we also understand that any of the information is found wrong, I/ we liable to be debarred. (iv) (a) I certify that I did not retire as an Engineer of Gazetted or as any Gazetted Officer employed on Engineering or Administrative duties in any Engineering Department of the Government of Goa during the last two years. I also certify that I have neither such a person under my employment nor shall I employ any such person within two years of his retirement except with the prior permission of the Government. (For individuals seeking enlistment in their own name). (b) we certify that none of the partners/Directors retired as an Engineer of Gazetted rank or as any Gazetted Officer employed on Engineering or Administrative duties in last two years. We also certify that we have neither under our employment any such person nor shall we employ any person within two years of his retirement except with the prior permission of the Government. (For partnership firms and limited companies). (strike out which ever is not applicable). Signature(s) of applicant(s) Name Signature Address 1. ........... ............. 2. ........... ............. 3. ........... ............. 4.