Supplier Application Form for Accreditation - Digi-products

Exor Management Services LimitedREGISTRATION AND APPLICATION FORMNOTE: Please read this introduction, it contains importantinformation about this application form.This document has been prepared to support applications for all levels of businessthat would like to become an Exor member to gain the following benefits:• Gain exposure to more business opportunities from the Public Sector market• Reduction in cost through the simplification of the bidding process – post accreditation the requirement to completeadditional pre-qualification forms will be minimised• Opportunity to offer your goods and services in new areas and to other local and national organisations that utilise Exor, viaweb based supplier selection systems• Confirmation that your company has adopted best practice in business management and complies with the required legaland regulatory processes, ensuring it is fit to work in the public sector• Utilise your Exor accreditation status to take advantage of a wide range of membership services, at preferential ratesPLEASE NOTE: This application consists of a registration/application form plus the following support information: (1) Client List,(2) Membership price list, (3) Health & Safety application, (4) Equal Opportunity information, (5) Terms and Conditions.Exor membership levels are based on a combination of factors and can be summarised as: risk (nature of your area of workcategory), contract value and required level of membership (local regional or national). The attached information will enable youto select the option that is best for your company.Exor Management Services has an active policy of assisting companies to complete the application forms and to reaching therequired accreditation standards. If you require assistance with any aspect of the application form please contact ourMembership Engagement Team on 08708 707272 or email apply@exorgroup.co.ukSECTION 1 – Your Exor reference number - if known (example AA1234)Q1.1 Which Authority are you applying? (see client list)SECTION 2 - Information about your companyQ2.1 Actual Name of Organisation:Q2.2 Organisation Trading Name:Q2.3 Type of Organisation: Limited PLC Sole Trader Partnership LL Partnership CharityQ2.4 Business activity, If your category is not shown please call the Engagement Team on 08708 707272 for assistance:CATEGORY OF WORKINCLUDESRISKLEVELAsbestos Asbestos HighDemolition Demolition HighElectrical Engineers Electrical Engineers HighGas Engineers Gas Engineers HighIntruder Alarm Intruder Alarm HighHeating & Ventilation Heating & Ventilation HighLaboratory Testing Laboratory Testing HighHighways & Roads. Forestry & Trees. Pest & Rot. Landscape &Maintenance. Marine Engineers. Telecoms & Network InstallationGeneral ConstructionSecurity & Surveillance InstallationHighTICKCatering, Waste & CleanersConsultants & ProfessionalsServices & TrainingSuppliers, Manufacturers &MerchantsOtherAny Work on customers premises.Restaurants & Catering.Waste Disposal & CleanersConsultants. ProfessionalsConsultants & Professionals requires Professional Indemnity InsuranceServices Provider. Care & Counselling.Hire & Leasing. Estate Agents & Letting. Training & Education Provider.Transport ServicesSoftware DevelopmentAll service providers not included above.Manufacturer. Retail & WholesaleInstitutes & Trade Associations. Cinema, Theatres & Entertainment.PublishingHighMediumMediumLowMembership Engagement team – 08708 707272 1Exor Management Services Limited – Accreditation Application Form v2 (2-2007)

Q2.5 Specify level of work you are prepared to undertake for this Authority. (figure should not exceed quarter of annual turnover)Less than £5k (Low risk) Bronze Less than £5k (High risk) Bronze Plus£5-£25k (Medium risk) Silver Greater than £25k GoldNOTE: If the category you have selected is less than £5k but ‘High’ risk category tick Bronze Plus box. If your category is‘High’ risk or have answered “Greater than £25K” the minimum accreditation level is GOLD For other selections tick Silver.Q2.6 Company registered number: (not applicable to sole traders and charities)Q2.7 Charity Number: Q2.8 Year of Incorporation or Registration:Q2.9 Trading address:Post CodeQ2.10 Does your company have a parent entity? Yes NoQ2.11 If Yes, give parent registration no: Parent company name:SECTION 3 – Contact information - primary contact (name of person to appear in the database)Q3.1 Title: Q3.2 First name: Q3.3 Last Name:Q3.4 Job title/department: Q3.5 Telephone No:Q3.6 Fax No: Q3.7 Mobile No:Q3.8 Email address: Q3.9: Website : www.Q3.10 Address:Post CodeSECTION 4 – Financial informationQ4.1 Number of employees: Q4.2 Year of commencement of trading:Q4.3 What was your last known annual turnover:Q4.4 Date of financial year end:Q4.5 VAT number (if applicable):Q4.6 Does your organisation hold an exemption certificate under the Construction Liability Scheme (CIS)? Yes No(Please attach a copy of photocard or schedule)SECTION 5 - InsurancesQ5.1 Do you have Public Liability Insurance? Yes No Limit of cover: Expiry date:Insurance company:Policy No:SECTION 6 – Banking detailsQ6.1 Name of bank: Q6.2 Sort code:Q6.3 Account No: Q6.4 Account name:Membership Engagement team – 08708 707272 2Exor Management Services Limited – Accreditation Application Form v2 (2-2007)

SECTION 7 – Licences and referencesQ7.1 Please check any current permits, licenses, authorisations, certifications and memberships of professional associationsappropriate to your business. (Documentary evidence will be required, please tick all that apply)ECA CORGI NICEIC NACOSS NFDC(demolition) HVCA Asbestos LicenceWaste Transport Licence ISO9000 ISO14000 ISO (other) Other (give details)Q7.2 If you are applying for GOLD accreditation you will need to supply a copy of your EMAS/Sustainability Policy(if in doubt call our Membership Engagement Team for advice or view www.emas.org.uk)SECTION 8 – Contract or work undertaken and referencesPLEASE NOTE – References are NOT required for ‘Bronze or Bronze Plus’ accreditation. Please go directly to Section 9Q8.1(Reference 1) Please supply 3 references each giving the following information:Client/company name: Contact name: Job title:Email address: Tele No: Fax No: Mobile:AddressPost CodeQ8.1(Reference 2)Client/company name: Contact name: Job title:Email address: Tele No: Fax No: Mobile:AddressPost CodeQ8.1(Reference 3)Client/company name: Contact name: Job title:Email address: Tele No: Fax No: Mobile:AddressPost CodeSECTION 9 – Equal OpportunitiesQ9.1 Do you undertake to comply with UK Equal Opportunities Legislation, minimum wagelegislation, the Race Relations Act and Codes of Practice, Disability Employment and Yes: No:Discrimination? (A copy of your Equal Opportunities Policy will be required).Q9.2 In the last three years has any court or employment tribunal upheld a finding of unlawfulracial discrimination or has the Commission for Racial Equality made a finding against your Yes: No:organisation in the course of a formal investigation on grounds of alleged unlawful discrimination?Q9.3 If Yes, please give further detailsMembership Engagement team – 08708 707272 3Exor Management Services Limited – Accreditation Application Form v2 (2-2007)

SECTION 10 – Ethnic monitoring (This information will be used for monitoring purposes only. It will not be taken into accountin deciding on select lists or in the award of contracts)Q10.1 EthnicOrigin ofManagement General(Foreman or Workforce Administration TotalEmployeesabove) (below foreman)WhiteBritishIrishOtherMixedWhite & Black CaribbeanWhite & Black AfricanWhite & AsianOtherAsian orAsian BritishIndianPakistaniBangladeshiOtherBlack orBlack BritishCaribbeanAfricanOtherChinese orOtherChineseOtherTotalQ10.2 Number of women in Organisation: Administration: Management: General workforce:Q10.3 Do you consider your organisation to be: Black lead: White lead: Other:Q10.4 Do you consider your organisation to be female lead? Yes: No:SECTION 11 – Health & SafetyQ11.1 Does your organisation operate Health And Safety procedures as required under Yes: No:current legislation? (see www.hse.gov.uk website for more information)Q11.2 If you answered Yes to (Q10.1) give brief details on a separate sheet of paper and attach it to the application form:Q11.3 Do you work on site at the Customer Premises? Yes: No:IMPORTANT:If you are applying for ‘Bronze’ accreditation you do not need to complete any further Health & Safety questions. However, if youare applying for ‘Bronze Plus, Silver or Gold accreditation you must complete one of the following forms:(1) Company’s with 5 or less employees need to complete Health & Safety Form 1 (Small Business)(2) Company’s with 6 or more employees need to complete Health & Safety Form 2If you are unsure please call our Membership Engagement Team who will advise you of the risk level for your work activity andwhich form is appropriate for your organisation - Telephone: 08708 707272Membership Engagement team – 08708 707272 4Exor Management Services Limited – Accreditation Application Form v2 (2-2007)

SECTION 12 – Background informationIMPORTANT: If your answer is ‘Yes’ to any of the questions in this section, please supplydetails on a separate sheet of paper and attach it to your application.Q12.1 Is any Director, Officer, Trustee, Partner, Proprietor or Senior Managers Yes: No:related to or associated with any person at Exor Management Services Limited?Q12.2 Is any Director, Officer, Trustee, Partner, Proprietor or Senior Managers Yes: No:related to or associated with any person at this Authority?Q12.3 Have any of the Directors, Officers, Trustees, Partners, Proprietors or Senior Yes: No:Managers of the Organisation been found guilty of Fraud in the last 5 years? Or beeninvolved in wrongful or fraudulent trading action or insolvency or any company orbeen involved in any company which has had a winding up order, receiver or administratorappointed or Personal Bankruptcy or has been disqualified from being a director?Q12.4 Have any of the Directors, Officers, Trustees, Partners, Proprietors or Senior Yes: No:Managers been convicted of any offence in any court in the UK or elsewhere (otherthan motoring offences not resulting in disqualification)? Excludes convictionsdeemed ‘spent’ under the Rehabilitation of Offenders Act.Q12.5 Your employees or subcontractors may have to attend sensitive property or sites Yes: No:where people under the age of 18 and over the age of 65 might be present. Are youprepared to give the names and addresses of employees or subcontractors and theiremployees to the purchasing authority or to provide current criminal record certificates?Q12.6 Has any purchasing authority, utility, government department or any council Yes: No:withdrawn or prematurely terminated any contract or enforced liquidated damagesin the last three years?Q12.7 Are there outstanding claims or litigation against your Organisation? Yes: No:(Other than settlement of existing or Final Accounts)Q12.8 Has your Company\Partnership ever been suspended, removed or terminated Yes: No:from any supplier list in the last five years?Q12.9 Indicate the approximate range your organisation operates?(Local = one authority where your category is available, Regional = up to 4 authorities where your category is available,National = Exor authorities where your category is available)Local: Regional: National:SECTION 13 – How to payFirst call our Engagement Team (08708 707272) to establish your membership fee and to discuss your method of payment.There are several way to pay for your membership fee:1. By cheque – payable to Exor management Services Limited and enclosed with your application.2. By BACS: Barclays Bank PLCSort Code: 20-35-35Account No. 504812113. Credit or Debit card – Please see the Credit/Debit payment form enclosed with this pack.Your payment should be pre-paid prior to receipt of your application or your cheque should accompany your application. Youwill them receive a receipt/invoice.Membership Engagement team – 08708 707272 5Exor Management Services Limited – Accreditation Application Form v2 (2-2007)

SECTION 14 – DeclarationI certify that all information provided is accurate and understand that Exor Management Services Limited will seek verification,including undertaking financial and credit checks. I give permission to Exor Management Services Limited to seek references,including a bankers reference and undertake Credit Reference Checks. I have read and accept the Terms and Conditions andhave particularly read and accept clauses 27 and 30 on liability. We undertake to notify Exor Management Services Limitedpromptly of any material changes in the Organisations position, for example: annual accounts, control of the Organisation andrevocation or lapsing of any certificates/licenses as listed in this form.Signature:Position in company:Print name:Company name:Date:Please make a copy of this document for your own reference and then post this application form including any additionalinformation and copies of certification to:Exor Management Services LimitedInnova HouseInnova Science ParkMollison AvenueEnfieldEN3 7XHAdditional contact information:Telephone: 08708 707272Fax: 01992 707272Email: clientservices@exorgroup.co.ukwww.exorgroup.co.ukMembership Engagement team – 08708 707272 6Exor Management Services Limited – Accreditation Application Form v2 (2-2007)