Due Diligence Questionnaire
This Due Diligence Questionnaire is required to assist Crown Agents when considering your
capability to perform any subsequent contract.
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You are required to complete all sections and answer all questions in English as accurately as
possible.
Crown Agents will not reimburse any costs incurred by bidders in connection with the
preparation and submission of their responses.
Failure to provide the required information or any of the supporting documentation may result in
rejection.
A copy of your completed Due Diligence Questionnaire, together with all supporting
documentation, will form part of any resulting contract with Crown Agents.
SECTION 1: COMPANY DETAILS
1.1 Company Contact
Company Name:
Registered address of Company:
Trading address of Company:
Telephone No:
Website:
Full Names and titles of all Directors (including
middle name if any):
(e.g. MD, Chairman, Company Secretary)
1.2 Details of Crown Agents’ main point of contact
Name:
Position:
Telephone No:
Email address:
1.3 Registration in country of domicile.
Copies of Registration Certificates enclosed?
VAT and/or
enclosed?
Tax
Registration
YES □/NO □
If your answer is No, explain reasons why and
provide details of date of formation, company
registration number and country of registration.
Certificate YES □/NO □
If your answer is No, explain reasons why and
provide details of VAT and/or Tax Registration
numbers.
1.4 Company’s total number of full time employees.
Total number of permanent (full time) employees:
Due Diligence Questionnaire – June 2015
Due Diligence Questionnaire
1.5 Technical Capacity
Is the Company a member of a Trade YES □/NO □ (IF “Yes” – provide details)
Association?
Name goods for which you act as an Authorised Name Product(s):
Certificates attached
Dealer/Distributor and attach copies of valid
Yes □/No □
certificates of authority:
If your answer is No,
please explain why
SECTION 2: FINANCIAL STANDING
2.1 Please provide the following financial information as an attachment to your completed Supplier
Due Diligence Questionnaire:
a) Copies of your Company’s audited accounts for the last two financial years or,
b) If your Company’s accounts for the last two financial years are unaudited because there is no
legal or regulatory requirement for your Company’s accounts to be audited, please provide
copies of your accounts signed by two of you directors for the last two financial years.
If you have not or cannot provide any of the above please give an explanatory statement:
SECTION 3: LITIGATION AND INVESTIGATIONS
3.1 Is there in your home country or elsewhere currently any pending or threatened material
litigation or other proceedings connected with your Company, its directors, officers or 10%
shareholders?
Yes □/No □
If you have answered “Yes” to question 3.1 please give an explanatory statement:
SECTION 4: ETHICAL HISTORY
4.1
In the last ten years has your Company or have any directors, officers, 10%+ shareholders or
owners of your Company, or any of its associated companies:
4.1a)
ever been bankrupt, insolvent, unable to pay his or its debts, sought protection from
his or its creditors, been wound-up or compulsorily dissolved by any court or tribunal
or been involved in any proceedings?
☐ Yes ☐ No
Due Diligence Questionnaire – June 2015
Due Diligence Questionnaire
4.1b)
ever been convicted of a criminal offence in any country related to fraud, theft,
bribery, corruption, money laundering, human rights violations (including anything
related to the abuse of children), anti-competitive or other unlawful or unethical
behaviour?
☐ Yes ☐ No
4.1c)
entered into any deferred prosecution agreement, settlement, resolution agreement
or similar arrangement with any law enforcement, prosecutorial or regulatory agency
or body relating to investigations or allegations of fraud, theft, bribery, corruption,
money laundering, human rights violations, anti-competitive or other unlawful or
unethical, behaviour?
☐ Yes ☐ No
4.1d)
ever failed to pay taxes that were due?
☐ Yes ☐ No
4.1e)
ever been listed by any country or organisation as being involved in terrorist or
money-laundering activities?
☐ Yes ☐ No
4.1f)
ever received or been the subject of allegations or press/media reports of
misconduct including fraud, theft, bribery, corruption, money laundering, human
rights violations, anti-competitive behaviour (including) bid-rigging, cartels, collusion
or coercion), damage to the environment, health or safety of employees or
employment or abuse of children?
☐ Yes ☐ No
4.1g)
ever voluntarily disclosed to any regulatory and/or law enforcement agency any
activity that may constitute bribery, money-laundering, fraud, or another criminal
offence involving fraud, corruption or unethical behaviour?
☐Yes ☐No
4.1h)
ever had cancelled or revoked or failed to hold any licence or membership of an
organisation required by law?
☐ Yes ☐ No
4.2
Are any directors, officers or 10%+ shareholders of your Company, or any of its associated
companies an employee or official in any state owned entity or public international
organisation?
☐ Yes ☐ No
4.3
Is your Company or any director, officer or 10%+ shareholder of your Company, or any of its
associated companies, currently sanctioned by, barred or suspended from doing business
with any government, national or public international organisation including any multilateral
development bank?
☐ Yes ☐ No
Due Diligence Questionnaire – June 2015
Due Diligence Questionnaire
If you have answered “Yes” to any of questions 4.1 to 4.3 please give an explanatory statement:
4.4 Do your directors and employees refuse to
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Yes □/No □
If you state No, please explain your
reasons in full
authorise
consent to
Ignore
any unlawful or corrupt behaviours, whether bribery,
extortion, fraud, deception, collusion, bid-rigging, cartels,
abuse of power, embezzlement, money laundering or similar
activity?
All bidders should be aware that it is a mandatory requirement that the successful bidder adopts and complies
with Crown Agents’ Ethical Code for Suppliers* as available as a download from the Supplier Download page on
Crown Agents website http://www.crownagents.com/supplier-downloads, which, among other things, require
the bidder to have in place policies and procedures prohibiting and preventing fraud, theft, bribery and
corruption, money laundering, and anti-competitive behaviour and requiring it to undertake due diligence on
its partners and sub-contractors. Failure to agree to adopt and comply with Crown Agents’ Ethical Code for
Suppliers and standard anti-corruption provisions for supply contracts will render a bid non-compliant.
* Means any individuals or organisations who provide goods and/or services to Crown Agents
CROWN AGENTS ANTI-FRAUD, BRIBERY AND CORRUPTION POLICY STATEMENT
“Crown Agents operates a zero tolerance approach towards all forms of fraud, bribery and corruption. It does
not give or accept bribes (including so called "facilitation payments") or any other illegal inducements, and will
not condone any such action by its employees, agents, representatives, contractors, suppliers or consultants.”
Crown Agents operates TEL, an independent confidential whistle-blower hotline for anyone wishing to report
concerns regarding fraud, bribery, corruption or other unlawful or unethical behaviour connected with its
business or operations. Details regarding TEL and how to access it can be found by following this link:
http://www.crownagents.com/about-us/ethics-and-compliance
SECTION 5:
DECLARATION
I certify that, to the best of my knowledge, information and belief, after having made due and careful
enquiries, that the above declaration and all information that has been supplied with this questionnaire is
correct, complete and not misleading. I understand that false or misleading information could result in the
Company’s exclusion from any procurement exercise undertaken by Crown Agents. I understand that Crown
Agents may carry out independent validation checks to verify the information contained in this
questionnaire.
Name of Company
Full Name of signatory
Signature
Due Diligence Questionnaire – June 2015
Title /Position
Date