Application Form for EOI 1. Organization Name 2. Address (Regd.
Office) : :
2 (a) Premises own/ rented (i) If own provide Tax paid receipt (ii) If rented copy of rent agreement has to be provided. 3. Address (Local Office)
4. Telephone No. & Fax 5. email 6. website 7. Chief of the Organisation 8. Telephone 9. email Id 10. Name of Contact personnel 11. Telephone 12. email ID 13. Type of the Organisation (Public Sector/Limited/Private limited/ Partnership, Proprietary /Society /Any other.) 14. Registration details (enclose certificates) :
: : : : : : : : :
13(a) Photo Id of Directors / Proprietor : :
Details of Quality certification like CMM Level/ ISO Etc.• • • • • •
Company Registration Tax Registration PF Registration ESI Registration Income-tax Registration PAN No (enclose certificate) : :
14(a) Name of the Banker and A/c No 15.2011 and to be renewed further up to
.00 lakhs only to be paid by DD in favour KEONICS.of Employees • • Technical Staff Non-Technical Staff
: : : :
21.1. as non-refundable fee for empanelling the firm. 23. (enclose Certificates) 17. Validity : Initially valid up to 31.3. of Offices/Centers (enclose the list) 20. KEONICS will follow the Karnataka Transparency in Public Procurement (KTPP) Act 1999 while awarding the work. 18. Client List (enclose the List of Clients) 19. An amount of Rs. Total No. Turnover of the Company for the last 2 years (enclose Balance Sheet). payable at Bangalore. Activities of the Company (enclose the Literature/ Brochure /Product Catalogue) • • • • • • Products manufactured IT Solutions developed Services offered Products/service marketed Training Any other activity
16. 22. No.
Signature with Name & Seal Place : Date :
Verification: I have verified all the documents furnished along with application form and found the application in order/not acceptable. forwarded/returned to the concerned. signed and sealed by the authorized signatory.
24.2012. based on the review and performance. The application is
Signature of the Verifying Officer Place : Date :
. Any other additional information the applicant wants to furnish in favour his/their business credentials: (Attach the documents) I hereby declare that the above information is true to the best of my knowledge. All attached copies to be certified as True Copy.31. 25.