Pre-Qualification Forms - Caribbean Cement Company Limited

Part No.: QMSR-300forfFForFforFOR OFFICIAL USE ONLYApplication No:Date Received:MTC Approved:MTC Rejected:GENERAL PRE-QUALIFICATION INFORMATION ON CONTRACTORSCARIBBEAN CEMENTCCOMPANY LIMITEDROCKFORT, KINGSTON 2All information submitted will be treated as confidentialPlease use additional sheets where required.ALL QUESTIONS MUST BE ANSWEREDANYONE FOUND GUILTY OF PRESENTING FALSE INFORMATION WILLBE AUTOMATICALLY DISQUALIFIEDRevision #1 Page 1 of 13Revision Date: January 1, 2010.Approved By: Materials Manager

Part No.: QMSR-3001.0 GENERAL INFORMATION1.1 Company Name: ___________________________________________________CorporationPartnershipLimited LiabilitySole ProprietorshipOther Please Specify1.2 Registered Business Address: _____________________________________________________________________________________________________________________________________________________________________________1.3 Operating Business Address: ____________________________________________________________________________________________________________________________________________________________________________1.4 Date Company Established: __________________________________________________________________________________________________________1.5 Telephone Number (s): _____________________________________________________________________________________________________________(Include After-Hours Telephone Numbers)1.6 Telefax Number (s): _______________________________________________1.7 E-Mail Address: __________________________________________________1.8 T.R.N #: _______________________________________________________1.9 G.C.T Registration Number: _________________________________________Revision #1Revision Date:Approved By: Materials Manager

Part No.: QMSR-3001.10 Certificate of Registration Number: ____________________________________1.11 Have you ever applied for Registration before? ( ) YES ( ) NOIf yes, state:(a) Trade Name and Date of Application: _____________________________(b) The Application was: ( ) successful ( ) unsuccessful ( ) no response2.0 DIRECTORS AND PARTNERS:List the names and addresses of three (3) of your Directors:-DIRECTORSADDRESSES1.2.3.Are any of the Directors, CCCL’s employees? YES ( ) NO ( )Do any of the Directors hold interest in any other Firm/Supplier registered with CCCL?YES ( ) NO ( )If yes, please give details on a separate sheet.Revision #1Revision Date:Approved By: Materials Manager

Part No.: QMSR-300GIVE THE NAMES AND TITLES OF KEY OFFICERS IN YOUROGANISATION:NAME OFEMPLOYEE/TITLE/PRESENTPOSITIONQUALIFICATIONS/YEARS OFEXPERIENCE1.2.3.4.5.6.Names of Authorised Contact (s) with CCCL: _____________________________________________________________________________________________________________________3.0 TRACK RECORD:3.1 How many years has your organisation been in business as a Contractor underyour present business name?____________________________________________________________________________________________________________________________3.2 What type of contract works/services has your company undertaken in the lastthree (3) years?Revision #1Revision Date:Approved By: Materials Manager______________________________________________________________________________________________________________________________

Part No.: QMSR-3003.3 (a) Give brief details of the type of work generally undertaken by yourorganisation:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(b)List at major projects undertaken in the last five (5) years. Give value andclient.YEARPROJECTBRIEF DESCRIPTIONCLIENTPROJECTVALUE$Revision #1Revision Date:Approved By: Materials Manager

Part No.: QMSR-3003.4 List at least (3) references for whom work was done over the last three years:CompanyName ofRefereeTelephoneNumberTelefaxNumber3.5 Has the business ever failed to comply with the fulfillment of any contract?YES ( ) NO ( )If yes, give brief details, including matters in litigation and/or arbitration:__________________________________________________________________________________________________________________________________________________________________________________________3.6 Has the business, while registered at CCCL, or in carrying out its contractto any company, been suspended? YES ( ) NO ( )If yes, give brief details, indicating reason and period of suspension:____________________________________________________________________________________________________________________________________3.7 Has the business, while registered at CCCL, or in carrying out its contract toany company, been terminated? YES ( ) NO ( )If yes, give brief details, indicating reason for termination:____________________________________________________________________________________________________________________________________Revision #1Revision Date:Approved By: Materials Manager

Part No.: QMSR-3004.0 RESOURCES:4.1 Personnel Summary:No. of Permanent (P)EmployeesNo. of Temporary(T) EmployeesManagersEngineers/OtherProfessionalsSupervisors/ForemenTechniciansCraftsmenClericalUnskilledTOTAL4.2 Provide a brief profile of the key personnel who will be responsible for theworks/services being applied for by the Company, on separate sheets.Revision #1Revision Date:Approved By: Materials Manager

Part No.: QMSR-3004.3 List the major items of equipment which your firm owns and which shall be madeavailable for use on the work for which this form is submitted. IncludeRegistration, Serial and Insurance Numbers for the equipment, where applicable:Type of EquipmentRegistrationNumberSerialNumberInsurancePolicyNumberRevision #1Revision Date:Approved By: Materials Manager

Part No.: QMSR-3004.4 Indicate below, details of the company’s base for handling works and servicesfor CCCL.Address of Company’s MainWorkshop Facilities:Floor Area (Sq.m) Indoor: Outdoor:5.0 FINANCIAL DATA:5.1 Annual Turnover/Revenue over the last three (3) years:2009: $ ___________ 2010: $ ___________ 2011: $ __________5.2 Financial References:Financial Reference StatementRange of Contract Work/Services

Part No.: QMSR-3006.0 INDUSTRIAL RELATIONS AGREEMENT WITH TRADE UNION:If yes, please indicate:Name of Union:Agreement Registration No.Recognition Certificate No.Expiration Date:7.0 SAFETY:(a) Does contractor have a Safety Programme Yes ( ) No ( )(b)Does contractor have a New EmployeeOrientation Programme? Yes ( ) No ( )© Does Contractor conduct on site safetyinspections Yes ( ) No ( )(i)If yes, who conducts these inspections?________________________________________________________________________________________________________________________(ii)Frequency of on-site inspections?________________________________________________________________________________________________________________________Revision #1Revision Date:Approved By: Materials Manager

Part No.: QMSR-3008.0 INSURANCE:Type ofCoverageLimit ofLiabilityName of InsuranceCompanyPolicyNumberExpiryDateWorkmen’sCompensationPublic LiabilityOtherEmployersLiabilityContractors,All riskOtherPlease attach copies of the above documents9.0 ISO CERTIFICATION9.1 Is your firm ISO Certified Yes ( ) No ( )9.2 If no, do you have plans ofbecoming so in the near future Yes ( ) No ( )Revision #1Revision Date:Approved By: Materials Manager

Part No.: QMSR-30010.0 CONTRACT WORKS/SERVICESIndicate below the Work Category and Contract Range for which your Companyis applying and has the necessary resources, expertise and experience to perform.Contractor should be capable of handling several contracts simultaneously.NAME OF WORK CATEGORY CONTRACT RANGE (*)(*) Contract Ranges ($000):

Part No.: QMSR-30012.0 DECLARATION:I/We hereby certify that the information provided is true and correct.FOR AND ON BEHALF OF:(Company’s NameNAME:(Official’s Name and Position in CompanySIGNATURE:DATE:Revision #1Revision Date:Approved By: Materials Manager