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Essar Refinery Integrated Management System

Vendor Registration Form

1.Corporate Information
Essar Oil Ltd.
Name Of Company : Qutbi Iron & Scale Mart

Address : 1182, Pankornaka, Ahmedabad - 380001

City : Ahmedabad Postal Code : 380001
State : Gujarat Country : India
Phone 1. +91-79-25321152 Fax No.2: +91-79-25382652
Phone 2. +91-79-25353728 Email: rsi_qism@msn.com
Fax No 1 Website :

Contact Person Name : Jujar A. Rangwala
Mobile No. : 1) +91-9879154652 2) +91-9227617352

2. Vendor Type (Pl tick in the box) 3. Tax Type (Pl tick in the box )
1. Chemical / Catalyst / Petroleum product supplier 1. VAT Registered - Raw Material supplier
2. Consumable Material & Spares Supplier 2. VAT Registered - Capital Goods Supplier
3. Transporter 3. CST Supplier
4. Contractor / Service Provider 4. VAT Un-registerd Vendor
5. Government / Statutory Body
6. Manufacturer
3. Industry Type ( Pl tick in the box)
1. Public Sector Unit 10. NSIC Registered Supplier
2. Private Business 11. Contractor
3. Dealer 12. Civil Service/Job
4. Catalyst Supplier 13. Electrical Service/Job
5. Chemical Supplier 14. Instrumentation/Electronics Service
6. Lube Supplier 15. Mechanical Service/Job
7. Import Vendor / Foreign Supplier 16. IT & Telecommunication Supplier
8. Cement Supplier 17. Raw material supplier/Govt. manufacturer
9. Supplier cum trader 18. Tor - Steel & Structural

4. Bank Details

Country of Bank : India Address : PO. Box. 101, Fuvara, Gandhi Road

Bank Name : Bank of Baroda
Bannk Account No. : 03280200003146 Bank Accounut Type: Current
Swift Code ( If Applicable) NA BIC (If Applicable)

5. Taxation Details. ( Kindly submit the photocopies of above certificates. )
Vendor ECC No.: Excise Commissionarate :
Excise Registration No. CST No. : 24570800243
Excise Range : CST Date : 30-06-1986
Excise Divison : VAT Reg. No. 24070800243
LST NO. : VAT Reg. Date.: 1/7/2002
LST Date.: Excise Indicator : Not Applicable
PAN No. :
MSMED (Micro, Small & Medium Enterprise) Status (If yes, please give details with the copy of certificate) :

Service Tax Registration :
With Holding Tax Type (As Applicable) :

6. Financial Information
2007-2008 2008-2009 2009-2010
1 Turnover
2 Profit After tax
3 Fixed Assets
4 Current Assets
5 Current Liablities

DOC No Rev No
EOL/COMM/P&C/R003 0

No. if applicable: S. Description of Machine & Make Accuracy & Range No of Machines Installed 1 2 3 4 5 11.List of Manufacturing Facilities ownes. List of Testing Facilities owned. Quality System Particulars 1 Is company ISO 9000/ ISO 14000 accredited Yes /No (If Yes.Organisation Strength Managerial Staff Supervisory Staff Skilled Labour Unskilled Labour 9.) 1 2 3 4 5 8. Control of Non Conformities & Measuring and Test Instruments and Conformance to safety requirements exists ( If Yes . no Customer Description of products suppliedTotal billing in last financial year (Rs. Equipment Description Accuracy & Range Last Calibration Date 1 2 3 10. List of Major customers Sr. Enclose copy of certificates) 2 System for Customer Satisfaction Rating . Signature and Seal of the CEO Of the Company. Enclose a brief of the systems ) We hear By declare that all the information required to be furnished for registration /        enlistment has been filled in correctly. if applicable S. No. DOC No Rev No EOL/COMM/P&C/R003 0 .Process Yes / No Control .7.