Department of Municipal Affairs ‫دائـــرة الشــــؤون البلديـة‬

Abu Dhabi City Municipality ‫بلديــة مدينــــة أبوظبـــى‬

Municipal Infrastructure & Assets Sector ‫قطاع البنية التحتية وأصول البلدية‬

‫نمـوذج التحقق من مصدر المـواد‬

Material Source Declaration Form
Project / Contract No: :‫ رقم العقد‬/ ‫المشروع‬
Contractor: :‫المقاول‬
Consultant: :‫االستشاري‬
Directorate / Section: :‫ القسم‬/ ‫االدارة‬
Civil Materials MEP Materials Irrigation & Landscape Materials

Submitted Material: :‫المادة المقدمة‬

Manufacturer/ Source Name: :‫ المصدر‬/‫اسم المصنع‬

Manufacturer/ Source Address : ‫ المصدر‬/‫عنوان المصنع‬
(city, emirate, country): )‫ البلد‬،‫ اإلمارة‬،‫( المدينة‬
Supplier/ Applicator Name: :‫ المطبق‬/‫اسم المورد‬
Supplier/ Applicator Address :‫ المطبق‬/‫عنوان المورد‬
(city, emirate, country): )‫ البلد‬،‫ اإلمارة‬،‫( المدينة‬

Reference is made to the following Abu Dhabi Executive Council Circulars:

- Circular No.2/1979, dated 25 Feb. 1979 regarding Resolution No. 30, Session 7/79 for import of
Companies for Goods and Materials required for them from abroad.
- Circular No. 02/99, dated 12 July 1999, regarding Resolution No. 20/A, Session 8/99, for support and
encouragement of local products, Item No. 2.

Since the proposed material is from outside the Emirate of Abu Dhabi, we make the following
declaration (check box as applicable):

a) To the best of our knowledge, the subject material is not manufactured locally in the
Emirate of Abu Dhabi.

b) Such material manufactured locally in the Emirate of Abu Dhabi does not fully
comply with the requirements of the Contract Documents (see note below). *

c) Local manufacturer of the subject material cannot supply the project on time and/or in
the quantities required (see note below). *

d) Such material manufactured locally in the Emirate of Abu Dhabi is not competitively
priced (see note below). *

* Note: Contractors must provide all supporting documents .

Contractor (Signature & Date): :)‫المقاول ( التوقيع والتاريخ‬

Consultant (Signature & Date): :)‫االستشاري ( التوقيع والتاريخ‬

Material Source Declaration Form, Rev. 2, Jan 2014