Supplier Questionnaire

1. Submitted by (Business Name(s)), including or a.k.a.

__________________________________________________________________________________________

__________________________________________________________________________________________
Street Address

________________________________________ _______________________________________________
City/ State Date Company Established

_____________________________ ______________ ____________________________________________

Principal Contact Title Telephone No.

E-mail Address: __________________________________________________________________________

2. Type of Firm (Tick one):

Sole Proprietor ______Partnership______ Professional Association _______Corporation_______

Public Private _______ Other ___________

__________________________________________________________________________________________
3. Date of Incorporation Business License Number(s) (Please attach evidence)

__________________________________________________________________________________________
4. Value Added Tax (VAT) Registration Number (Please attach evidence)

5. Affiliated Companies (Provide complete names, addresses and indicate whether Parent (P) or Subsidiary(S)

__________________________________________________________________________________________
Name Address

__________________________________________________________________________________________
Name Address

Company must be 51% owned, controlled, and operated by one of the above groups

6. Executive Directors/Partners:

Name Responsibility

__________________________________________________________________________________________
Name Responsibility

__________________________________________________________________________________________
Name Responsibility
__________________________________________________________________________________________
Name Responsibility

__________________________________________________________________________________________
Name Responsibility

(Please attach copy of Memorandum and Article of Association)

7. Number of personnel in Organization:

Management ___________ Administrative ____________Engineering ___________Shop ___________

Field/Marketing ___________

7B. No of PFAs in place for the Organisation and staff ____________________________________

Names of PFAs ________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

8. Major suppliers:

____________________________________________________________________________________________________
Name Address Telephone

Name Address Telephone

9. Primary Banker(s)

Name

__________________________________________________________________________________________________
Address

_________________________________ _________________________________________________________
Telephone Account No /Type

________________________________________________________________________________________________
Name

_________________________________________________________________________________________________
Address
______________________________________ ____________________________________________________
Telephone Account No/Type

10. Insurance Carrier:

Name: ____________________________________________________________________

Address: _______________________________________________________________________

Telephone No.: __________________________________________________________________

11. Typical projects completed in the past two years:

_____________________________________________________ __________________________________________
Project Name & Location Contract (N)

____________________________________________________________________________________________________
Owner/Rep. Name & Tel. No E-mail Address

_____________________________________________________ __________________________________________
Project Name & Location Contract (N)

_____________________________________________________________________________________________________

Owner/Rep. Name & Tel. No E-mail Address

_____________________________________________________ __________________________________________
Project Name & Location Contract (N)

_____________________________________________________________________________________________________

Owner/Rep. Name & Tel. No E-mail Address

12. Do you currently have relatives employed by Stanbic IBTC Bank Plc?

Yes _____ No _____

If yes, list the name(s) of any family relations.

____________________________________________________________________________________________________

________________________________________________________________________________

13. Are you currently or have you formerly been employed by Stanbic IBTC Bank Plc?
Yes _____ No _____

If yes, list the dates of employment.

Date of Hire: ___________________________

Date of Exit: ____________________________

14. Release
The undersigned is submitting the information contained herein with the understanding that it will be used to
assist in determining the qualifications of this organization to perform miscellaneous work for Stanbic IBTC
Bank Plc and further guarantees the truth and accuracy of all statements made herein. Stanbic IBTC Bank Plc is
authorized to make use of the statements and information furnished herein and otherwise made available from
any source whatsoever.
The undersigned will accept Stanbic IBTC Bank Plc’s determination of qualifications without prejudice. The
undersigned hereby releases Stanbic IBTC Bank Plc, and those providing information to Stanbic IBTC Bank Plc
pursuant the this authorization, form all actions, claims and/or liabilities of any kind arising from provision or
use of information about the undersigned and the undersigned hereby waives any rights the undersigned may
have to pursue such actions and/or claims.

__________________________________________________________________________________________
Complete Legal Name of Business

__________________________________________________________________________________________
By (Authorized Signature) Title Date

__________________________________________________________________________________________
Attested to by (Signature) Title Date

PLEASE NOTE THAT THIS DOCUMENT IS PART OF THE BANK’S VENDOR EVALUATION
PROCESS.