Request for Quotations (RFQ)
RFQ No. 14_037 Amended
RFQ Issuance Date: August 22, 2014
Submission of Quotations
Quotations must be delivered by mail, courier service, or e-mail to:
JSI / USAID | DELIVER PROJECT
Attention: Alan Rogosch
Rua Kamba Simango 58
Maputo, Mozambique
Phone: +258 21 484 080
Email: arogosch@mz.pfscm.org
Hard copies of quotations must be provided in a sealed envelope.
Validity
Quotations shall remain valid for 30 calendar days from the deadline for receipt of
quotations.
Supply Quote for the following:
Line
Item
1
2
3
Product Description
Forms
Livro de Lista de Embalagem
Livro de G.Remessa/G.Entrada
Ficha de Stock
Unit
(pages)
Quantity
50
50
1
45 700
45 700
300 500
Specifications:
Please see Annex 1 with table with specifications for each form. In addition, designs for
each form are provided and are intended for quotation purposes only. Higher resolution
versions of the forms will be provided to the selected vendor upon signing of the
purchase order.
Quotation Requirements:
1. Vendors must include in their quotation the length of time they require, upon
signing of purchase order, to print and deliver materials.
2. Vendors must provide past performance information including three (3)
references and a description of similar print jobs at these quantities.
3. Quotations must include unit price and total price by item.
4. VAT (IVA) should be quoted separately from the total price.
5. Quotations must include validity of prices, no less than 30 days.
6. Vendors must submit completed certifications (Part D, Attachments 1-6)
attached to this RFQ.
7. Quotations should certify as to the financial viability and resources of the
company to provide the proposed goods, which includes year-end financial statements
for the last three years.
8. Vendors must be local.
Deadline for Receipt of Quotations:
The deadline for the receipt of quotations by the JSI / USAID | DELIVER PROJECT is 17:00 local
Maputo Time), September 3, 2014. JSI / USAID | DELIVER PROJECT reserves the right not to
consider a quotation received after the deadline.
Payment
Vendors may choose one of the following payment options:
1. Total payment received after all printed materials are delivered;
2. Payment based on the incremental delivery of printed materials per an approved delivery
schedule to be agreed upon between JSI and the Vendor;
Proofs must be delivered no later than three (3) working days upon contract award. JSI may
terminate contract if no proofs are delivered within this period. Good performance bank
guarantee will then be deposited in favor of JSI.
Vendor must submit an electronic version of forms in PDF, CorelDRAW or other desktop publishing
software, and the JSI/USAID | DELIVER PROJECT must approve these proofs before printing begins.
Vendor will submit invoices corresponding to each delivery. Invoices will be paid net 30 days from
the date of delivery, submission of invoice and acceptance by our local office.
Final printed materials will be delivered to:
JSI / USAID | DELIVER PROJECT
Attention: Alan Rogosch
Rua Kamba Simango 58
Maputo, Mozambique
Phone: +258 21 484 080
Any questions should be submitted to the “Submission of Quotations” address as listed above.
RFQ No. 14-037
Page 2 of 18
Quotation Form
Page ____ of ____
Validity of Quote: _______ calendar days from deadline
Quoter Name and address:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Phone: _________________ Fax: ___________________
E-mail: ______________________________
Please note:
1.
2.
3.
4.
Prices are to be stated in local currency.
All goods offered must be suitable for use in Mozambique
Estimated delivery time after placement of order.
In case of discrepancy between unit price and total, the unit price shall prevail.
Item
No.
Price
Description of Goods
Unit
Quantity
Unit
Price
Total Price
Est. delivery
time
TOTAL
Authorized Signature: ____________________________________________
Date: _____________________
RFQ No. 14-037
Page 3 of 18
PART D: ATTACHMENTS TO THE RFQ
1. Certification Regarding: Prohibition on the Promotion or Advocacy of the Legalization or
Practice of Prostitution or Sex Trafficking (Acquisition) (June 2010)
2. Contractor Code of Business Ethics (April 2010)
3. Information Regarding Responsibility Matters (April 2010)
4. Certification of Toxic Chemical Release Reporting (August 2003)
5. Certification and Disclosure Regarding Payments to Influence Certain Federal Transactions
(Sep 2007)
6. Certification Regarding Debarment, Suspension, or Proposed Debarment (December 2010)
7. Technical Specifications (Especificaçoes Técnicas)
RFQ No. 14-037
Page 4 of 18
ATTACHMENT 1
REQUIRED CERTIFICATION
As a condition of accepting a subcontract under this RFQ, the selected vendor is required to
certify to the following mandatory clause:
Prohibition on the Promotion or Advocacy of the Legalization or Practice of Prostitution or Sex
Trafficking (Acquisition) (June 2010)
(a) This contract is authorized under the United States Leadership Against HIV/AIDS, Tuberculosis,
and Malaria Act of 2003 (Pub.L. No. 108-25), as amended. This Act enunciates that the U.S.
Government is opposed to prostitution and related activities, which are inherently harmful and
dehumanizing, and contribute to the phenomenon of trafficking in persons. The contractor shall not
use any of the funds made available under this contract to promote or advocate the legalization or
practice of prostitution or sex trafficking. Nothing in the preceding sentence shall be construed to
preclude the provision to individuals of palliative care, treatment, or post-exposure pharmaceutical
prophylaxis, and necessary pharmaceuticals and commodities, including test kits, condoms, and,
when proven effective, microbicides.
(b)(I) Except as provided in (b)(2) and (b)(3), by its signature of this contract or subcontract for HIV I
AIDS activities, a non-governmental organization or public international organization awardee/sub
awardee agrees that it is opposed to the practices of prostitution and sex trafficking because of the
psychological and physical risks they pose for women, men, and children. [1 0]
10 The following footnote should only be included in awards to Alliance for Open Society
International (AOSI), Pathfinder, or a member of GHC or InterAction (with the exception of DKT
International, Inc.):
(b)(2) The following organizations are exempt from (b)(I): the Global Fund to Fight AIDS, Tuberculosis
and Malaria; the World Health Organization; the International AIDS Vaccine Initiative; and any
United Nations agency. (b)(3) Contractors and subcontractors are exempt from (b)(I) if the contract
or subcontract is for commercial items and services as defined in FAR 2.101, such as
pharmaceuticals, medical supplies, logistics support, data management, and freight forwarding.
(b)(4)Notwithstanding section (b)(3), not exempt from (b)(I) are contractors and subcontractors that
implement HIV I AIDS programs under this contract or subcontract by: (i) providing supplies or
services directly to the final populations receiving such supplies or services in host countries;
(ii) providing technical assistance and training directly to host country individuals or entities on the
provision of supplies or services to the final populations receiving such supplies and services; or
(iii) providing the types of services listed in FAR 37 .203(b)( 1 )-( 6) that involve giving advice about
substantive policies of a recipient, giving advice regarding the activities referenced in (i) and (ii), or
making decisions or functioning in a recipient's chain of command (e.g., providing managerial or
supervisory services approving financial transactions, personnel actions).
(c) The following definitions apply for purposes of this provision:
"Commercial sex act" means any sex act on account of which anything of value is given to or
received by any person.
RFQ No. 14-037
Page 5 of 18
"Prostitution" means procuring or providing any commercial sex act and the "practice of
prostitution" has the same meaning.
"Sex trafficking" means the recruitment, harboring, transportation, provision, or obtaining of a
person for the purpose of a commercial sex act. 22 U.S.C. 7102 (9).
(d) The contractor shall insert this provision in all subcontracts.
(e) Any violation of this provision will result in the immediate termination of this award by USAID.
(f) This provision does not affect the applicability of FAR 52.222-50 to this contract.
The Offeror (below named organization or firm) certifies that it has ( ) has not ( ) instituted a
policy explicitly opposing prostitution and sex trafficking as required under this Request for Proposal
and any possible subsequent subcontract.
Offeror:
_______________________________________
Authorized Signatory: _______________________________________
Print Signatory Name: _______________________________________
Title:
_______________________________________
Date:
__________________
RFQ No. 14-037
Page 6 of 18
ATTACHMENT 2
REQUIRED CERTIFICATION
As a condition of accepting a subcontract under this RFQ, the selected vendor is required to
certify to the following mandatory clause:
CONTRACTOR CODE OF BUSINESS ETHICS (APR 2010)
In accordance with FAR 52.203-13, CONTRACTOR CODE OF BUSINESS ETHICS (APR 2010) the
subcontractor ____ has ____ does not have current active Federal contracts and grants with
total value greater than $5,000,000. The subcontractor ____ is____is not a small business.
The duration of the subcontract is____is not____ less than 120 days. The subcontractor
has____does not have___ a Code of Business Ethics which has been provided to employees.
The subcontractor is ___ is not___ exempt from the Code of Business Ethics. In accordance
with the subcontractor’s Code of Business Ethics the contractor has ____does not
have____a Business Ethics Awareness and Compliance Program that encourages and
otherwise promotes a culture of ethical conduct and commitment to comply with the law
and an internal control system that prevents and detects criminal conduct. In accordance
with the Business Ethics Awareness and Compliance Program the subcontractor
does___does not____ provide effective training to employees in this area.
The subcontractor shall disclose, in writing, to the prime contractor and the agency office of
the Inspector General (OIG), with a copy to the Contracting Officer, whenever, in connection
with the award, performance, or closeout of this contract or any subcontract thereunder,
the subcontractor has credible evidence that a principal, employee, agent, or subcontractor
of the subcontractor has committed a violation of Federal Criminal law involving fraud,
conflict of interest, bribery, or gratuity violations in Title 18 of the US Code or a violation of
the civil False Claims Act.
_____________________________________
Signature
_____________________________________
Printed Name
_____________________________________
Company Name
_____________________________________
Date
RFQ No. 14-037
Page 7 of 18
ATTACHMENT 3
REQUIRED CERTIFICATON
As a condition of accepting a subcontract under this RFQ, the selected vendor is required to
certify to the following mandatory clause:
52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (APR 2010)
(a) The offeror [ ] has [ ] does not have current active Federal contracts and grants with
total value greater than $10,000,000.
(b) If the offeror checked "has" in paragraph (b) of this provision, the offeror represents, by
submission of this offer, that the information it has entered in the Federal Awardee
Performance and Integrity Information System (F APIIS) is current, accurate, and complete
as of the date of submission of this offer with regard to the following information:
(l) Whether the offeror, and/or any of its principals, has or has not, within the last five years,
in connection with the award to or performance by the offeror of a Federal contract or
grant, been the subject of a proceeding, at the Federal or State level that resulted in any of
the following dispositions:
(i) In a criminal proceeding, a conviction.
(ii) In a civil proceeding, a finding of fault and liability that results in the payment of a
monetary fine, penalty, reimbursement, restitution, or damages of $5,000 or more.
(iii) In an administrative proceeding, a finding of fault and liability that results in(A) The payment of a monetary fine or penalty of $5,000 or more; or
(B) The payment of a reimbursement, restitution, or damages in excess of $100,000.
(iv) In a criminal, civil, or administrative proceeding, a disposition of the matter by consent
or compromise with an acknowledgment of fault by the Contractor if the proceeding could
have led to any of the outcomes specified in paragraphs (c)(1 )(i), (c)(1 )(ii), or (c)(1 )(iii) of
this provision.
(2) If the offeror has been involved in the last five years in any of the occurrences listed in
(c)(1) of this provision, whether the offeror has provided the requested information with
regard to each occurrence.
(d) The offeror shall enter the information in paragraphs (c)(1)(i) through (c)(1)(iv) of this
provision in F APIIS as required through maintaining an active registration in the Central
Contractor Registration database at http://www.ccr.gov (see 52.204-7).
RFQ No. 14-037
Page 8 of 18
"Principal" means an officer, director, owner, partner, or a person having primary
management or supervisory responsibilities within a business entity (e.g., general manager;
plant manager; head of a division or business segment; and similar positions).
___________________________________________
Signature
___________________________________________
Printed Name
___________________________________________
Company Name
___________________________________________
Date
RFQ No. 14-037
Page 9 of 18
ATTACHMENT 4
REQUIRED CERTIFICATION
As a condition of accepting a subcontract under this RFQ, the selected vendor is required to certify
to the following mandatory clause:
52.223.13 CERTIFICATION OF TOXIC CHEMICAL RELEASE REPORTING (AUG 2003)
By signing this offer, the offeror certifies that:
1) As the owner or operator of facilities that will be used in the performance of this contract
that are subject to the filing and reporting requirements described in section 313 of the
Emergency Planning and Community Right-to-Know Act of 1986, (EPCRA) and requirement
section 6607 of the Pollution Prevention Act of 1990 (PPA) (42 U.S.C. 13106), the offeror will
file and continue to file for such facilities for the life of the contract the Toxic Chemical
Release Inventory Form (Form R) as described in sections 313(a) and (g) of EPCRA and
section 6607 of EPA; or
2) None of its owned or operated facilities to be used in the performance of this contract is
subject to the Form R filing and reporting requirements because each such facility is exempt
for at least one of the following reasons: (check each block that is applicable)
3) ( ) (i) The facility does not manufacture, process, or otherwise use any toxic chemicals listed
in 40 CFR 372.65;
4) ( ) (ii) The facility does not have 10 or more full-time employees as specified in section
313(b)(1)(A) of EPCRA, 42 U.S.C. 11023(b)(1)(A);
5) ( ) (iii) The facility does not meet the reporting thresholds of toxic chemicals established
under section 313(f) of EPCRA, 42 U.S.C. 11023(f) (including the alternate thresholds at 40
CFR 372.27, provided an appropriate certification from has been filed with EPA);
6) ( ) (iv) The facility does not fall within the following Standard Industrial Classification
(SIC)codes or their corresponding North American Industry Classification System sectors:
(A) Major group code 10 (except 1011, 1081, and 1094,
(B) Major group code 12 (except 1241)
(C) Major group codes 20 through 39.
(D) Industry code 4911, 4931, or 4939 (limited to facilities that combust coal and/or
oil for the purpose of generating power for distribution in commerce).
(E) Industry code 4953 (limited to facilities regulated under the Resource
Conservation and Recovery Act, Subtitle C (41 U.S.C 6921 et seq.), or 5169, or
5171, or 7389 (limited to facilities primarily engaged in solvent recovery services
on a contract or fee basis); or
( ) (v) The Facility is not located in the United States or its outlying areas.
______________________________________
Signature
______________________________________
Printed Name
______________________________________
Organization and Date
RFQ No. 14-037
Page 10 of 18
ATTACHMENT 5
REQUIRED CERTIFICATON
As a condition of accepting a subcontract under this RFQ, the selected vendor is required to certify
to the following mandatory clause:
52.203-11Certification and Disclosure Regarding Payments to Influence Certain Federal
Transactions (SEP 2007)
Please complete OMB Standard Form LLL which is attached and the certification below:
The offeror, by signing its offer, herby certifies to the best of its knowledge and belief that
no Federal appropriated funds have been paid or will be paid to any person for influencing
or attempting to influence an officer or employee of any agency, a Member of Congress,
and officer or employee of Congress, or an employee of a Member of Congress on its behalf
in connection with the awarding of this contract.
If any registrants under the Lobbying Disclosure Act of 1995 have made a lobbying contact
on behalf of the offeror with respect to this contract, the offeror shall complete and submit,
with its offer, OMB Standard Form LLL, Disclosure of Lobbying Activities, to provide the
name of the registrants. The offeror need not report regularly employed officers or
employees of the offeror to who payments of reasonable compensation were made.
___________________________________
Signature
___________________________________
Printed Name
___________________________________
Company
___________________________________
Date
RFQ No. 14-037
Page 11 of 18
ATTACHMENT 6
REQUIRED CERTIFICATION
As a condition of accepting a subcontract under this RFQ, the selected vendor is required to certify
to the following mandatory clause:
Protecting the Government’s Interest When Subcontracting with Contractors Debarred,
Suspended, or Proposed for Debarment (DEC 2010)
This is___is not___ a commercial subcontract. This subcontract is ___ is not___ for the
procurement of off-the-shelf items. The total price of the subcontract is___is not___greater
$30,000.
The subcontractor or its principals have ____ or have not ____ been debarred, suspended,
or proposed for debarment.
______________________________________
Signature
______________________________________
Printed Name
______________________________________
Company Name
______________________________________
Date
RFQ No. 14-037
Page 12 of 18
DISCLOSURE OF LOBBYING ACTIVITIES
Approved by OMB
0348-0046
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See
reverse for public burden disclosure.)
1. Type of Federal Action:
2. Status of Federal Action:
3. Report Type:
a. contract
a. bid/offer/application
a. initial filing
b. grant
b. initial award
b. material change
c. cooperative agreement
c. post-award
For Material Change Only:
d. loan
year
quarter
e. loan guarantee
date of last report
f. loan insurance
4. Name and Address of Reporting Entity: 5. If Reporting Entity in No. 4 is a Subawardee, Enter Name
and Address of Prime:
Prime
Subawardee
Tier ______, if known :
Congressional District, if known :
4c
6. Federal Department/Agency:
Congressional District, if known :
7. Federal Program Name/Description:
CFDA Number, if applicable : _____________
8. Federal Action Number, if known :
9. Award Amount, if known :
$
10. a. Name and Address of Lobbying Registrant
( if individual, last name, first name, MI):
b. Individuals Performing Services (including address if
different from No. 10a )
(last name, first name, MI ):
11. Information requested through this form is authorized by title 31 U.S.C. section
Signature:
1352. This disclosure of lobbying activities is a material representation of fact
upon which reliance was placed by the tier above when this transaction was made
or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This
information will be available for public inspection. Any person who fails to file the
required disclosure shall be subject to a civil penalty of not less than $10,000 and
not more than $100,000 for each such failure.
Print Name:
Title:
Telephone No.: _______________________
Date:
Authorized for Local Reproduction
Federal Use Only:
Standard Form LLL (Rev. 7-97)
PRINT
RFQ No. 14-037
Page 13 of 18
INSTRUCTIONS FOR COMPLETION OF SF-LLL, DISCLOSURE OF LOBBYING ACTIVITIES
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the initiation or receipt of a covered Federal action, or a material
change to a previous filing, pursuant to title 31 U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for
influencing or attempting to influence an officer or employeeof any agency, a Member of Congress, an officer or employeeof Congress, or an employeeof a Member of Congress in
connection with a coveredFederal action. Completeall items that apply for both the initial filing and material change report. Refer to the implementing guidance published by the
Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a followup report caused by a material change to the information previously reported, enter
the year and quarter in which the change occurred. Enter the date of the last previously submitted report by this reporting e ntity for this covered Federal
action.
4. Enter the full name, address, city, State and zip code of the reporting entity. Include Congressional District, if known. Che ck the appropriateclassification
of the reporting entity that designates if it is, or expects to be, a prime or subaward recipient. Identify the tier of the subawardee,e.g., the first subawardee
of the prime is the 1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization filing the report in item 4 checks "Subawardee," then enter the full name, address, city, State and zip code of the prime Federal
recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizationallevel below agency name, if known. For
example, Department of Transportation, United States Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (item 1). If known, enter the full Catalog of Federal Domestic Assistance
(CFDA) number for grants, cooperative agreements, loans, and loan commitments.
8. Enter the most appropriate Federal identifying number available for the Federal action identified in item 1 (e.g., Request for Proposal (RFP) number;
Invitation for Bid (IFB) number; grant announcement number; the contract, grant, or loan award number; the application/proposal control number
assigned by the Federal agency). Include prefixes, e.g., "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the Federal amount of the award/loan
commitment for the prime entity identified in item 4 or 5.
10. (a) Enter the full name, address, city, State and zip code of the lobbying registrant under the Lobbying Disclosure Act of 1995 engaged by the reporting entity
identified in item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10 (a). Enter Last Name, First Name, and Middle
Initial (MI).
11. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number.
The valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is estimated to average 10
minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503.
RFQ No. 14-037
Page 14 of 18
7. ANNEX 1: DOCUMENT SPECIFICATIONS
Item
#
Modelo
Nome do
documento
Formato
Capa Frente
Apresentação
Capa
Trás
Encadernação
Picotado
(Papel
carbonico)
Prenumerado
Tipo de
papel
Gramas
N°
Pgs
Tipo
Cores
N° Total
de
Folhas
Branca,
Amarela e
Verde
Branca,
Amarela,
Azul, Verde
1
N/A
Livro de Lista de
Embalagem
A4
Papel
100 g
Imprimida
Retrato
Cartão
300 g
Colado
Original e
Duplicado
S
Bond
45
50
Triplicado
2
CMAM-MOD 2
Livro de
G.Remessa/G.Ent
rada
A4
Papel
100 g
Imprimida
Paisagem
Cartão
300 g
Colado
S
Bond
45
50
Quatroplicado
3
CMAM-MOD 3
Ficha de Stock
A5
N/A
Imprimida
Retrato
N/A
N/A
Original,
Duplicado
e
Triplicado
N/A
N
Cartão
300
1
Única (frente
e verso)
RFQ No. 14-037
Page 15 of 18
Verde
Total
Quantidade
150
Nº
linhas
em
cada
pagina
50
200
5
700
1
20
500
700
Nº Guia de
Remessa
Lista de Embalagem
DATA:
TRANSPORTADOR:
DESTINATARIO:
MATRICULA:
Nr. Nr Serie
Nr. Code
Descricao
Unidade (Fardo,
Caixa,)
Page___/___
Nr. LOTE
Em balagem
Qt. Total un./ Peso Total/
fardo
fardo
Volum e
Total/fardo
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
ENVIADO POR:
DATA
TRANSPORTADOR:
DATA
(Deve ser assinado pelo Motorista)
RECEBIDO POR:
RFQ No. 14-037
DATA
Page 16 of 18
CMAM - Modelo 02-REMILD
Original (Branco)
REPÚBLICA DE MOÇAMBIQUE
GUIA DE REMESSA
MINISTÉRIO DA SAÚDE
CENTRAL DE MEDICAMENTOS E ARTIGOS MÉDICOS
Depósito Fornecedor:
Unidade Dependente:
Distrito:
N° de Requisição:
Fornecimento
N°Total de v olumes:
Devolução
Data da requisição:
Prov íncia:
N°
Expirado
Acumulado
Data da recepção
Data da remessa:
Preenchido pelo Deposito Fornecedor
Preenchido pela Unidade Dependente
Duplicado (Amarelo)
Designação
FNM /
SIMMAM
ENTRADA
Nome
Forma de
Contagem
N° de Lote / Código /
Série
Prazo de
Validade
Quantidade
Pedida
Quantidade Fornecida
(QF)
Valor
Quantidade Recebida
(QR)
Diferença
MZM
QR
QR - QF
1
2
3
4
Triplicado (Azul)
5
INFORMAÇÃO SOBRE A REMESSA:
Elaborado por (Nome)
Companhia de Transporte
Quatroplicado (Verde)
Nome do Motorista
Valor da remessa:
Rúbrica
Data (DD/ MM/ ANO)
Matrícula do Veículo:
Rúbrica
Data (DD/ MM/ ANO)
INFORMAÇÃO DA RECEPÇÃO:
Armazém de destino
RFQ No. 14-037
Recebido por (Nome)
Rúbrica
Data (DD/ MM/ ANO)
Rúbrica do Motorista
Data (DD/ MM/ ANO)
Page 17 of 18
Modelo de Ficha de Stock
REPÚBLICA DE MOÇAMBIQUE
FICHA DE STOCK
CMAM - Modelo 03
MINISTÉRIO DA SAÚDE
CENTRAL DE MEDICAMENTOS E ARTIGOS MÉDICOS
Unidade Sanitária:
Distrito:
Prov íncia:
Enfermaria de :
FNM
Data do
movimento
Farmácia de:
Designação (Nome,
dosagem e forma
Origem/Destino do movimento
Prazos de Validade
CMM
N° de
Documento
Entradas
Ajustes
Negativos
Ajustes
Positivos
Saídas
Stock
Existente
"Pedidos" (Lote or
Série)
Rubrica
Stock
Existente
Pedidos
Rubrica
… Transporte :
Data do
movimento
Origem/Destino do movimento
N° de
Documento
Entradas
Saídas
… Transporte :
RFQ No. 14-037
Page 18 of 18