l,iir lMCwortdwide

promoting the highest standards of ethical

-ar-",r-*rrm** ([MC) Bfi;td;t""iJulty -ommittea to
transpalency,
corrupt and f.auduIent practicesand reqUke
behavioul throughout our business' We condemn conduct ourselves
We will perform all seMces with integrity and
integrity and honesty in all aspects oT our work
reputation and experience
*ittitt,i pror"rsionafirm expected of a firm with our internationat standing, a robust Business
approach to all forms of corruplion and
Fundamentalto this is the adoption ola zero tolerance'
E+hi-.
^^li.v u/irhin rhe firm.
regarding allof the questio* *':t
Please provide answers to and intormatron :"j':'^::::j:y::":::T::::
sepu."re sheet. ro the extent permitted by
raw, arl
:;:nil#ffi;:r;;;;.;;.;,;;;rretl an,,",.on
"
disclosed to any third parties without
prlor
iniormiion provided in this form will be held in confidence and not
notice and aPProval

relating to:
-.,Due Diligence
Project title: Rural Access Pr;gramme 3 (RAP3)

Project fD#: 7901 5691

Part 1 Organisation Details

Aastha General Store and Suppliers
Name of Organisatlon
Jumla' Nepal
Chandannath Municipality 6,lumla Bazar'
Address of Head Office

Website information

Ms Rastru KathaYat
Name of ow n e r4lM3sag**tsr

Name(s) of former Owne(s)/CEO(s)/Managing

Directo(s)

Part 2 Business lnformation

Director
To be completed by the owner/cEO/Managing

a. E E Corporation n Non Profit O Other !

Sole proprietorship Partnership

lf other Please specifY here:

nNo
b. ' ls this organisation r'egistered? lf so'
please note the
and registration nLlmber below:

Nepal, (PAN) 600401524,

ver1lan20t6
LMcWoadwidcDuoDlliScnceQuestionnaire(Parinerorga^isalions)
 |1ii. iMCworldwide

c. ls the entity an organisalion listed on a public

(tock nYes XNo
exchange? lf so, please provide relevant details belowl

lf applicable, please list any parent companies or subsidiaries below:

NA

e. : Does anv Pubtic Official or government entity have any E Yes XNo
^. .^ni/^llin. ihtare<i in vdrrr

f. : Please |ist the fu|| names and date of birth of a|| Principa|s for your organisation {Note: the term
,.Pfincioal,,inc|udes,butisnot|imitedto,theexecutiveofJicers,partners,owners,dIrectors,trusteesor
others who exercise control over Your organisation)

NA

Part 3 compliance, Health and SafetYl

_:_
a. : Does the organisation have an institutionalised Financial and E Yes
internal controls policy? lfso, please attach or provide details

b. Does the organisation have an occupational health and safety I Yes I No

policy (oHs) policy? lf so, please attach or provide details below:
: ,

PIeasestatewhethertheorganIsatIonmeetstheleSislatiVerequirementofcompuIsoryinsurance
country or
where business willtake place and please attach the certification or provide details by
:

countries.

r Answering "Yes" to anY of Part 3 does not implY an automatic bar toworkingwith IMC Worldwide'
Page 2 of4 rMcworldwide oue DiliSnce Questionnaire (Pa'tner Organkations)_Ver llan 2016
 Part 4 Relationships
TobecompletedbYtheindividLlalorowner/cEo/managinSdirectoroftheorganlsatlon
Please State wherheri

Official {as that term i5 defined in Part 7 below)

I Yes I No
a. You are a current Public

Official n Yes I No
a current Public
b. Your organisation employs

i brother' spouse or child) C Yes I No

.. ur. au a'o'"
'ou are
,ou - - father' sister'
\"'e mother'
clo5e rc'drv! (l
'elative
\.-l )f a Public Official
Yes
Yes xI
' Prrblic
a rPublic
relative u'h^ u""" D
L-l No
ls a close- -^r^rn'' who i< d
wno is
rs
relatNe
d. of your organisation h'
Principalof
Any Principal
Anv
has

officral

For any person dentifie, .,, ,:::.:"1.1:i::;:;ffi::::] l"J::J"llffjilJJi,l1l1iJ,lJJij"ll5;",

ano resP"'"l""ll^", "
relatronshrp to you or the organisation --^l*^.*-"t-*'
sheet or paper
i' n"eded' attach a separate
:::#;$;i;;;;; tr
"d'ditionat 'p"cu

Part 5 Diselosures
Directorofthe organisation
To be completed by the owner/Managing .

investigated' E Yes 8No

ur organisation) ever been
" :ffi::{il:iJ"1l,l!'i1iiiJ.l;,;;;;cated
in criminar' corrupt'

unet-hical or r'rnlawful conduct?

ll Yes tsNo
Has the orBan,sarion, o''*'Yo'l:J'lt ::,:[X'i:;J#il'gt;li:Hil"'
with' (onvrr
been investigaled {or, charged -" ,
or unlawful condurt ?
iili""i -.?"0t. ,""nical-

a violatron I lYes lil N.

issued a sanction or committed
c. Has ttre organisation ever been
of law or regulation?
, r^-^"itr6+ha.ir.Imciance! below:
please describe the circumstances
lf yes to any ofthe above'

Part 6 Additional Declarations

Director of the orsanrsallon'
To be completed bv the Owner/Managine

(Parr^er orsanisations)-ver t lan

2016
rMcworldwide oue DilBenco Q(esrioinake
 ......'...
th,r iMCworidwldc

Pleas provide any :dditionat information below that would assist the company in perfolrnrng
6 oue
drlrgence review. lf mofe space is needed, please attach a sepaf:te sheet.

ro lre completed bv the Ownef/Manaeins Director of the oreanjsation.

herebv certifvthatl

io the best of my knowledge, att inforrnatjon ir this response is truthful, cofrect and compjete;
I h:ve read rhe
rrrrormatron at the websites notd below and I am familiar with the requirements
of these anticorruDtion stat!tes:
1r!tlrs-!yi!!l!"1!i
r.',!
'1r! !!i:lli Lut rul!l!!!g
.]1!il_-4!!
'..p
read th," definrtion of pubtic Ofticiaj below and declare that nither
lr., v.r
t, nor any of my immediate tamity
iemrrr, are Public Offjciats, except as previousty disctosed.
hdve never paid, approved for payment or otherwise provided,
directly Dr tndirectlv, an!.thjng of vatue to a pubtic
ottr'ial for anv improper, corrupt or illegal purpose, nor will t; and I have never creatd
a flse Invorce or otherwise
rr'i'irp'rrted documentation to disSuise making a payment or otherwise providing
anything of varue to a pubric
111 . .ii ior any purpose, nor wi L

\(r'::'P!blicOffrcial"meanianyperson,whethertectedorappointedwhoholdsanexecuriv,
legrslatrve,
;omrf/strative or judrciat office or position in any pubti entit, inctuding any
internationat agency. tn addjtion,
' P!blic Official" ifcludes any person who performs public
functions in any branch of the ratronat, state, tocat or
muficrpal govrnment of ary country or rerritory who xercises a public
i.inction, by employmenr or unoer contracr,
lor rny public entity, agency or enterprise of suh country or territory, in.luding
state owned or ontrolled
ntrpriss.Thed;finitiofof,'pubtiOfficiat,,atsoincludesanyofficiatot.potiticatpartyoranycandidatefor

herebv acknowredge that hdve been inforrred by Mc worrdwide that it may seek to obtarn an Investigative report
l|r'rr will inciude personar information regarding rne, incruding but not
rimited to, educationar and work historv, work
relrrencs, and .riminar convictions or arrest records if alowed, in order
io assist rMc worldwide in determining
whether it can enter inro an agreement with me or my orSanisstion. herehy
consent to rMc worrdwide conducting
rhis ifvestigatlon and obtaining such reports as may be provided to
tMc worldwide by other tirrns subcontracted for

iurtlrer hereby acknowrdge that I have reviewed the rMcworrdwide Ltd Business
Elhics poricy (attached) and mv
orgrnisatron will comply with a requirements set out in the code.

5rgnature:

Ms.Rastru Kathayat

iitlel Proprietor

1,1, Jar 2017