ANNEXURE – A :DECLARATION

Tender notice No: PWD/D.XXIV/10-4-E/02/2019-20 Date: 28/05/2019.

Work no. :

Name of work :

I/We, ________________, hereby declare that currently I/ We am/ are having the following
works in hand.
Name of Division Date of Stipulated Agreement Cumulative
work under which start of date of value agreement
work is being work completion value
executed
1 2 3 4 5 6

Further, I/we declare that the information furnished above are true and correct to the best of my
knowledge.
Submitted: Executive Engineer
WD XXIV,
PWD, Bicholim Goa.
Date:
Place: