Supplier Pre-Qualification Questionnaire

Requested by MAZARINE ENERGY ROMANIA S.R.L. (“ MER”)

Note from MER:

The information below is requested solely for conducting internal checks for the purpose of anti-bribery, anti-
corruption and anti-money laundering compliance and will be kept confidential.

General Information
By signing below, I certify that I have performed such procedures and inquiries as necessary to ensure that the
answers provided in this document are accurate and complete to the best of my knowledge.

Name:

Title:

Date:

1. Company Profile & Contact Details

1.1. Business Information
1.1.1. Please state your company’s full ALEXIS FLOR NORD SRL
corporate
1.1.2. Please state your company’s registered Loc. Trip,str.Dumbrava,no.196b,jud.Satu Mare
address
1.1.3. Please state your company’s operational Adresa de punct de lucru daca difera de adresa de
address (if different than your company’s inregistrare
registered address)
1.1.4. What is your company’s tax registration RO 30910563
number (for VAT purposes, if applicable)?
1.1.5. What is your company’s registration J30/850/2012
number with the Trade Registry or similar
companies’ register?
1.1.6. How long has your company been in 7
business?
1.1.7. Parent companies and ownership Parent Company Ownership %
percentage of each (if applicable)

1.1.8. Please provide the names and Name Nationality

nationalities of the shareholders, up to Ravas Maria RO
and including the ultimate beneficial
owners**. If your company is publicly

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1.1. Business Information
held*, state only the shareholders holding
more than 5%.
PLEASE NOTE that a simple indication of
the direct shareholders of your company
does not suffice as an answer to this
question. Please attach a separate
document showing the group structure.
1.1.9. Does your company or any of its owners Nu este cazul
(excluding public shareholders) or directors
have an ownership interest above 5% in any
other organization? If yes, please provide
details.
1.1.10. Has your company changed ownership in Nu
the last three (3) years? If yes, please
provide details on how many times and
who were former and current owners
1.1.11. What is the legal organization of your □ limited liability company □ joint stock company
company? (choose one) (unlisted)
□ partnership □ joint stock company
(listed on stock
exchange)
□ trust □ state-owned
□ other:
1.1.12. If your company is publicly held*, what is n/a
the percentage of public ownership?
1.1.13. If your company is publicly held*, on which n/a
stock exchange(s) are the shares listed? (if
within the last 5 years, please also indicate
the date of the listing)
1.1.14. If your company is publicly held*, provide n/a
the major (>5%) shareholders (public and
non-public).
1.1.15. If your company is a Trust, is it owned by n/a
bearer shareholders***?
1.1.16. State the total number of staff (permanent Permanent Contract
and contract) 23
1.1.17. Have you had any work stoppage in the last Daca au fost lucrari oprite/sistate in ultimii 5 ani. Daca da
5 years (for any reason, e.g. industrial de ce?
action, safety incident, etc.)? (if yes please Nu
1.1.18. explain)
List all company Directors and Officers, their 1.Ravas Maria /03.04.1976/Romana
dates of birth and nationalities. 2.
Nume/data nasterii/nationalitatea 3.
conducerii …….
1.1.19. Does any individual named in Questions Daca ai relatii cu, conducerea/personalul MER?
1.1.8 and 1.1.188 above have any
relationship to a MER employee which
could create a conflict of interest, or
appear to do so? (If so, please provide
1.1.20. Is any of the persons named in Questions 1.
1.1.8 and 1.1.18 above employed by any
other companies or entities that have a 2.

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 1.1. Business Information
beneficial interest in the services or goods 3.
that you may provide to MER? (if yes,
please give the name of each company, ……..
the individual concerned and his/ her
1.1.21. What are the principal activities of your Activitatiile principale
company? Lucrari constructii industriale
1.1.22. List the name(s) and title(s) of the 1.Ravas Maria/administrator
individuals who will be responsible for 2.
working with our organization. 3.
Persoanele de contact+ functia lor ……
1.1.23. Does your company need an authorization Autorizatii necesare pentru a presta servicii( cred ca sunt
and/or permit in order to provide the cele legate de ISCIR, ANRE etc.dar ar trebui intrebat)
services/goods to MER? If yes, please state ISOO 9001,14001,18001
which authorization and/or permit, if such
is/are in place and for which duration.
* Publicly held refers to companies whose shares can be freely bought and sold on a stock exchange.
** Beneficial owner means any natural person that ultimately owns or controls the company by:
i. Owning directly or indirectly a number of shares or voting rights ensuring control over the company; the owners of 25%
plus one share are considered to meet this criterion;
ii. Otherwise exerting control over the management of the company.

*** Bearer Shareholder is defined as: an individual or entity which has possession at any particular time of the ownership
documents of a trust or company registered by bearer shares. Bearer shares are ownership certificates which do not have the
owners’ names marked on them.

2. Business Ethics
2.1. Ethics Related Policies
2.1.1. Do you hire underage persons younger than 16 no
years old?
2.1.2. Do you import main raw materials and/or products no
from any of the countries for which there are
economic and/or and trade sanctions in place, as
follows:
a) administered and enforced by OFAC (The Office
of Foreign Assets Control of the U.S. Department
of the Treasury) that are described or referenced
at
http://www.ustreas.gov/offices/enforcement/ofac/
, as amended and/or updated from time to time;
b) imposed by the European Union as
indicated in the „Consolidated list of persons,
groups and entities subject to EU financial
sanctions” currently available at
http://eeas.europa.eu/topics/sanctions-
policy/8442/consolidated-list-of-persons-groups-
and-entities-subject-to-eu-financial-sanctions_en ,
as amended and/or updated from time to time (If
2.1.3. so, please
Does your provide
companydetails)
have policies in place to ensure
compliance with anti-corruption and anti-money
laundering laws? If yes, do they take into account
compliance with the U.S. Foreign Corrupt Practices
Act and UK anti-bribery legislation?

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 Please provide a copy or a brief description of their
contents.
2.1.4. Does your company agree to abide by the MER yes
Business Ethics Standards (including, without
limitation, the MER Code of Conduct) in any future
work with MER?
2.2. Additional Ethics Questions
2.2.1. Does any Romania government official* have any no
direct or indirect ownership or other financial
interest in your company or any of its affiliates? (If
yes, please provide details)
2.2.2. Is any owner, director, officer, or key employee** no
of the company a current or former Romania
government official*? (If yes, please provide
details)
2.2.3. Does any owner or director of your company have no
any family or business relationship (including acting
as an agent or consultant for, or holding common
ownership of any business enterprise or
partnership) with any current Romania government
official*? (If yes, please provide details)

2.2.4. Is your company or any owners or key no

employees** of your company identified on any of
the following sanctions lists: OFAC’s List of
Specially Designated Nationals; the U.S.
Commerce Department’s List of Denied Parties;
the HM Treasury Consolidated List (If so, please
2.2.5. Has your company or any of its affiliates, or any ? daca ai fost suspendat sa faci business?
current director, officer, or key employee** ever Nu
been suspended from doing business in any
capacity as a result of fraud, misrepresentation,
corruption, bribery, money laundering or other
related activities? (If yes, please provide details)
2.2.6. Has your company made any public disclosures no
involving fraudulent or corrupt misconduct or
improper accounting, including bribery to any U.S.
or U.K. authorities, including the U.S. Department
of Justice, the Securities and Exchange
Commission, or the U.K. Serious Fraud Office? (If
yes, please provide details)
2.2.7. Have any government officials* been entertained, no
received gifts or per diems, participated in any
trips, or otherwise been provided with any money
or other thing of value by your company or any of
its affiliates in connection with the goods/services
to be provided to MER? (If yes, please provide
2.2.8. details)
Has your company or any of its affiliates or current no
officers paid or received any incentive, finder’s fee,
commission or gratuity in connection with the
goods/services to be provided to MER? (If yes,
please provide details)

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2.2.9. Has your company or any of its affiliates, or any ?daca ai fost urmarit pentru frauda, coruptie, etc?
current director, officer, or key employee** ever Nu
been charged with, or investigated for fraud,
misrepresentation, corruption, bribery, money
laundering or other breach of regulations? (If yes,
please provide details)
* Government official is defined as: '(i) a natural person who is or who has been entrusted with prominent public functions, at a
senior level (not including middle-ranking or more junior officials) such as heads of state, members of parliament, members of
government, members of the governing bodies of political parties, members of supreme courts, of constitutional courts or of other
high-level judicial bodies, ambassadors, high-ranking officers in the armed forces, managers of public institutions and authorities,
directors, deputy directors and members of the board or equivalent function of an international governmental or quasi-
governmental organization; (ii) family members (namely brothers/sisters and their spouses, the spouse, the parents, the children
and their spouses) of the persons entrusted with prominent public functions; (iii) persons publicly known to be close associates of
persons entrusted with prominent public functions.' After the lapse of one year after the date when the person ceased to hold a
prominent public function, such person shall no longer be considered Government Official.
** Key employees are defined as: 'any employee with executive or management authority of the company and of any company
that is the ultimate beneficial owner (as defined above).'

3. Financial & Legal

3.1. Financial Data
3.1.1. Please provide the following financial Data USD FY 2015 FY 2016 FY 2017
data for previous 3 years (enter year): Sales/Revenue
Cifra de afaceri Operating Income
[also known as
Earnings Before
Interest & Taxes
(EBIT)]
Total Assets
Current Liabilities
Total Liabilities
3.1.2. If your company is a new venture (less Next Current
than 3 years old), what is the estimated Year Year
sales/ revenue range for the current and
next business year? Plan?
3.1.3. Has your company or any of its no
affiliates filed for bankruptcy anytime
in the last 3 years? (if yes, please
3.1.4. Company Taxpayer No.:
3.1.5. VAT No.: (for Romania and all EU
companies)
3.1.6. USA Federal ID (FEIN) If the case

4. Quality Attributes
4.1. Quality Management System
4.1.1. Do you have a certified quality management system? (If yes, please yes
provide copy of certification)
4.1.2. If no, do you have a documented quality management program

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5. Health, Safety, Security & Environment (HSSE)
Please refer to the hereby attached Appendix 1.

6. Technical & Product Questions

6.1. Product/ Material/ Goods
6.1.1. List the country/ies and location where the final ?unde realizezi productia?
product is/are manufactured/ assembled. Beneficiari
6.2. Service
6.2.1. Is the service provided at a MER owned facility? La locatia lor?
6.2.2. If no, is the service provided at a place owned by your Pe proprietate proprie
company?
6.2.3. Please review the following statements and select the
one that best describes your company.
 all personnel performing work are employees of yes
the organization
 some of the personnel are contracted Yes (personal angajat pe proiect)?
6.2.4. Please review the following statements and select the
one that best describes your company.
 all equipment and tools utilized are owned by your partially
company
 some of the equipment and tools are leased yes
 some of the equipment and tools are owned by yes
contractors
**END**

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