ෙපා.ෙකා.ප.

1 ආකෘ පය
பவ பஒச 1
FORM PCA 1

ෙකාා  වැය .5,000,000  ඉමවන ට. ෙටඩක ෙහා් ෙටඩක සඳහා ෙහා්
ෙවෙව කට කරන අෙයා්ත, උප අෙයා්ත, ෙයා්ත ෙහා් නාකයා යාපං කර ලැම සඳහා
වන ඉ පය
ஒபததி ெசல 5,000,000 பாைவ வமிட ேகவதாரகாகேவா அல
அவ சாபேலா கவராக ைண கவராக, பரதிநிதியாக அல நியமதராக பதி
ெசவதகான வணப

Application for registration as Agent, Sub-Agent,Representative or Nominee for or on behalf

of Tenderer where Contract cost exceeds Rs.5,000,000

Tender Number: RSC/N/T&C/CEDE/LAYING OF

ෙටඩරය ඉප කර ලබන ෙපා ෙකාා ෙම  නාමය:-
ேகவபதிர ேககபட பகிரக ஒபததி க ெபய :-
Short title of Public Contract for which tender is made:-
HDPE & DI PIPES FITTINGS-THIKKAM/2023/115
Item Name: Laying of HDPE & DI Pipes, Fittings,
Specials, Valves and Accessories for
Distribution Pipe Line Extension at Thikkam &
Polykandy Area for Pointpedro Water Supply
Scheme.
Closing Date: 2024-04-09
Description: Laying of HDPE & DI Pipes, Fittings,
Specials, Valves and Accessories for
Distribution Pipe Line Extension at Thikkam &
Polykandy Area for Pointpedro Water Supply
Scheme. Contract No: RSC/N/T&C/CEDE/L

}
1. ඉකෙ සණ නම
வணபதார  ெபய ACCESS INTERNATIONAL (PVT) LTD
Full Name of Applicant

}
2. ඉකෙ නය
வணபதார கவ ACCES TOWERS 278, UNION PLACE,COLOMBO 02.
Address of Applicant

}
3. ඉකෙ ජාකවය
வணபதார நான Sri Lankan
Nationality of Applicant

4. ඉක ෙටඩක සඳහා ෙහා් ෙවෙව කට කරන අෙයා්ත ද, උප අෙයා්ත ද ෙයා්ත ෙහා් නාක ද යන
බව:-
(අෙයා්තයා ෙලස ප කර ලැෙ සහකය ෙමයට අණන.) ෙපා.ෙකා.ප. 10 ආකෘ පය
வணபதார ேகவதாரராகேவா அல அவ சாபேலா கவராக , ைணகவராக , பரதிநிதியாக அல
நியமதரா என றிபக (பஒச 10 ஆ பவதிகான கவ நியமன சாறித இைணக
Whether applicant is the agent, sub-agent, representative or nominee for or on behalf of the tenderer(attach Certificate of
appointment as agent)on Form PCA 10:-

}
5. ෙටඩකෙ සණ නම
ேகவதார  ெபய ACCESS INTERNATIONAL (PVT) LTD
Full name of tenderer

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 }
6. ෙටඩකෙ නය
அதைகய ேகவதார கவ ACCES TOWERS 278, UNION PLACE,COLOMBO 02.
The address of such tenderer

}
7. ෙටඩකෙ ජාකවය
அதைகய ேகவதார நான Sri Lankan
The nationality of such tenderer

8. ෙටඩක ෙපා ෙහා් ෙපෟගක සමාගම වන ට එ -

ேகவதார பகிரக அல தனயா கபனெயாறாக
இமிட -
Where the tenderer is a Public or Private company state- Private Company

}
(අ) යාපං අංකය
(அ)அத பதி இலக PV5409
(a) It's Registration Number

}
(ආ)සෑම අධෂවරෙය සබධෙයම පහත සදහ ස්තර සපයන
(ஆ)அத ஒெவா பணபாள சபதமாக கீ வ தகவ
(b) The following information in respect of each of it's Directors

ක දරන ෙකාටස්


මාණය ශතය
නම නය ජාකවය ජාකවය
பறப වශෙය
ெபய கவ நான ைவதி
நான
Name Address Nationality பகள வத

Nationality
of Origin Percentage of shares
held

NO.44/6,DE MEL WATTE ROAD,2nd

FERDINANDO, DON DILHAN SRILATH Sri Lankan Sri Lankan
LANE,KOSWATTA,NAWALA

PERERA, SHAMAL JOSEPH SHAVINDRA NO.23,TICKLE ROAD,COLOMBO - 08 Sri Lankan Sri Lankan

MENDIS,SHEVANTHA HARINDRA
NO 32/2,SCHOOL LANE,NAWALA Sri Lankan Sri Lankan
SUDARAKA

FERNANDO , DALPADORUGE ANTON NO.81/5,ISIPATHNA

Sri Lankan Sri Lankan
ROHANA MAWATHA,COLOMBO 5

NO.8/1,GREGORY'S ROAD,COLOMBO
MUNASINGHE SAUMAYA DHARSHANA Sri Lankan Sri Lankan
-07

NO 122/38,BELLANTARA
GOMEZ RANJAN JOHN SURIYAKUMAR Sri Lankan Sri Lankan
ROAD,ATTIDIYA,DEHIWALA

JOSHUA JOSEPH CHRISTOPER NO.37/2,PEDRIS ROAD,COLOMBO - 03 Sri Lankan Sri Lankan

FERNANDO, THANTULAGE NO.6/8,D. ROBERT ALWIS

Sri Lankan Sri Lankan
THEOPHILUS BEDE CLAUDE MAWATHA,BORALESGAMUWA

NO 150/19H,BELLANTARA ROAD,
PERERA, SURESH DILHAN Sri Lankan Sri Lankan
DEHIWALA

9. ෙටඩක ෙපෟගක සමාගම වන ට, එ සෑම ෙකාටස් ය සබධෙය පහත සඳහ ස්තර සපයන:-
ேகவதார தனயா கபனெயாறாக இமிட அத பதார ஒெவாவ ெதாடபாக பவ
தகவகைள தக ::-
Where the tenderer is a private company, give the following information in respect of each of its shareholders:-

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 ක දරන ෙකාටස්

මාණය ශතය
නම නය ජාකවය ජාකවය වශෙය
ெபய கவ நான பறப
நான ைவதி
Name Address Nationality பகள வத

Nationality
of Origin Percentage of shares
held

PERERA SUMAL JOSEPH SANJIVA NO.23,TICKLE ROAD, COLOMBO 08 Sri Lankan Sri Lankan 100

10. ෙටඩක ෙවළඳ ආයතනය ෙහා් තැනැතෙ ෙකාෙසා්යම වන ට වාපාර ආයතනෙ සෑම ෙකාටස්කව
සබධෙය ෙහා් ෙකාෙසා්යමෙ සෑම තැනත සබධෙය ෙහා් පහත ස්තර සපයන:-
ேகவதாரர ஒ ம அல ஆகள ைணபாக இமிட, மதி பகாள அல
ைணப ஆ ஒெவாவ ெதாடபாக பவ வபரகைள தக.
Where the tenderer is a Firm or Consortium of persons give the following information in respect of each partner of firm or
person of Consortium:-

වාපාර ආයතනෙ ෙහා්

ෙකාෙසා්යමෙ ල
තවය ෙකෙර දරන
 කම ශතය
නම නය ජාකවය ජාකවය වශෙය
ெபய கவ நான பறப மதி /
நான ைணப
Name Address Nationality ைவதி நிதிசா
Nationality
of Origin அகைறய
வத
Percentage of Financial
interest in the
firm/Consortium

ඉහත සඳහ ඉ පෙ සඳහ ය ස්තර මෙ/ අපෙ දැෙ හැයට සත හා වැර බවට මම/ අ ෙගෟරව
බමානෙය හා අවංකව රා/සහක කර කාශ කර ./.
ேமேபாத வணபதி உள வபரக என/எகள நபைக எய அளவ உைமயானைவய
ெசைமயானைவ என ………………………………. ஆகிய நா/நாக சதிய ெசகி ேற/கிேறா. பயபதியக,
வவாசமாக, ெமயாக ெவளபதி உதிபகிேற./கிேறா.

I dilhan suresh perera do swear/solemnly sincerely and truly declare and affirm that to the best of my/our belief the
particulars contained in the above application are true and correct.

................................................................ ................................................................
ල ාව/இலசைன/Seal අසන/ைகெயாப/Signature
Name: DILHAN SURESH PERERA
Designation: Director

Page 3 of 4
20............................න වන ෙමන ................................. මා ඉෙ  ෙදන ල./ඥා ෙදන ල.

20…………….. மாத …………. ஆ நாளாகிய இ என னைலய சதிய ெசயபட /உதிபதபட

Sworn/affirmed before me to/at ..........................................................this ..........................day of ................... 20 ................

................................................................ ................................................................
ල ාව/இலசைன/Seal සාම /  ෙකාමසාස් .
சமாதான நதிவா/சதியப ஆந
Justice of the Peace /Commissioner for Oaths

ෙමම කාශය තැනැත සබධෙය වන ට එම තැනැතා  ද, සංස්ථාව වන ට එ අධෂවරෙය ෙහා්

ෙක  ද, වාපාර ආයතනය ෙහා් ෙකාෙසා්යම වන ට වාපාර ආයතනෙ ෙහා් ෙකාෙසා්යමෙ යම
ෙහා් හකවෙග බතරය  රා කාශ කළ/ඥා ය/ය.
இ, தனயா ஒவ வடயதி அவரா, தாபன ஒறி வடயதி அத பணபாள
ஒவரா அல ெசயலாளரா ம அல ைண ஒறி வடயதி எலா அல
அதிகபயான பகாளகளா அல ைணப ஆகளா சதிய ெசயபட அல
உதிபதபட ேவ.

This statement must be sworn or affirmed in the case of an individual by him, in the case of a corporation by a Director or
Secretary thereof, in the case of a firm or consortium by all or a majority of the partners or persons of consortium.

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