NATIONAL OFFICE FOR TECHNOLOGY ACQUISITION AND PROMOTION
(Established by Decree No. 70. 1979 as amended by Drecree N0. 82, 1992)
“TAA” PRE-QUALIFICATION FORM – PART 1
(To be used for the registration of Technology Acquisition agreement)
To:
Originated By:
DIRECTOR/ CHIEF EXECUTIVE OFFICER
NATIONAL OFFICE FOR TECHNOLOGY
ACQUISITION AND PROMOTION
Name…………………………………………………………….
NO 1, BLANTYRE STREET OFF ADETOKUNBO
ADEMOLA CRESCENT, WUSE II
P.M.B 5074, WUSE, ABUJA., NIGERIA.
Last Name……………………………………………………….
First Name……………………………………………………….
Middle
Name…………………Alias…………..........................
…………………………………………………….
Acting as……………………………………………..................
For Office Use Only
Chairman of the Board of Directors
………………………………………………………..
TAA-PQ FORM NO………………………………...
File no……………………………………………….. of…………………………………………………………………
Name of Company
Date Received……………………………………...
Industrial Sector…………………………………….
……………………………………………………………………
Small
Medium
Large Scale
No and Date of Incorporation
Processed By…………………………………………………..
Recommendation………………………………………………
……………………………………………………………………
……………………………………………………………………
Registered Address: Number/ Street/City/State
Approved
Approval Status
Pending
Bring Forward
Request Personal Appearance
Not Approved
Date:
…………………………………………………………………….
Current Address Branch Address
……………………………………………………………………
Major line of Business
…………………………………………………………………….
Telephone/Fax/E-mail/www
Date Filled:
BUSINESS PROCESS DATE
ITEM REQUEST
STATUS
001 Corporate Business(Commercial)
Manufacturer
How would you classify your business status?
Distributor
Strategic Partner
Partner
Edu. Institution
002 Government & Agencies
Gov.
Govt. Agent
003 User Classification
Heavy User
Medium Scale
Small Scale User
004 Total Number of Customer Base
How Many?
005 Do you have an operating license? If yes attach a
Yes
No
copy herewith
006 Total Annual Turnover last year
N
007 Total Import Tax/ VAT paid last year
N
REMARKS
Total Workforce
USD$
NATIONAL OFFICE FOR TECHNOLOGY ACQUISITION AND PROMOTION
(Established by Decree No. 70. 1979 as amended by Drecree N0. 82, 1992)
“TAA” PRE-QUALIFICATION FORM – PART 2
(To be used for the registration of Technology Acquisition agreement)
ITEM
008
009
010
010
011
BUSINESS PROCESS DATE
REQUEST
STATUS
Corporate Member
Are you and/ or your Company
Professional Member
an accredited Member of any of
Associate Member
the following IT Bodies in
Affiliate Member
Nigeria?
(Tick where applicable)
(Tick where applicable)
CPN
NCS
ITAN
ISPON
Is the license meant to be used by
Yes
No
one or more organisations? If Yes,
indicate the names of the
organisations and turnover
Supply information on the foreign
technicians/ consultants who will
be render services locally, if any
Projected Volume Sale
1-10 User Product Licence
11-20 User Product License
21 – 50 User Product License
51 – 100 User Product License
100– 200 “
“
“
210– 500 “
“
“
501– 1000 “
“
“
1001– 2000 “
“
“
2001– 3000 “
“
“
3001-5000 “
“
“
above 5000 User Product
License
Agreement and Licence Type
Operation systems
(Tick where applicable)
Server
Propriety Software
Free Software License
Advanced Server
Semi-Free Software license
SQL
SHAREWARE
Oracle
Public Domin Software
………………………..
Education Software License
Workstation
SHIRNK WRAP licenses
MS W/S license
OTHERS:
……………………………..
Banking application
Duration of Agreement
Oil Drilling Application
6Months
12Months
Gas Processing Appl.
18Months
24 Months
Insurance Application
36 months
5years & Above Medical/ Hospital Appl.
Office Suite Application
Date of Signing the Agreement
Word Processing
…………………………………..
Spread Sheet
Accounting Application
Effective Date of the Agreement
Training Applications
…………………………………...
R& D Applications
Expiring Date of Agreement
…………………………………
REMARKS
Per Quarter
Please specify product
Brand Name Where
applicable.
NATIONAL OFFICE FOR TECHNOLOGY ACQUISITION AND PROMOTION
(Established by Decree No. 70. 1979 as amended by Drecree N0. 82, 1992)
“TAA” PRE-QUALIFICATION FORM – PART 3
(To be used for the registration of Technology Acquisition agreement)
ITEM
012
013
014
015
016
017
018
019
020
021
022
information about the (Transferee) or recipient Party
REQUEST
STATUS
Is this year your first application Yes
No
to NOTAP
State Total Fund Transfer
USD$
Value
Estimated Import Tax/Vat
N
Supply Banker’s Name and
address
Supply correspondent Banker’s
Name and address
Name and address of Recipient
Company (Incl: Tel. E-mail,
Telex, Fax, www etc.)
Country of Incorporation
Town
State
Zone
Main Business Activity
Location and address of
production plant related to this
agreement
Name/s of all product to be
imported. Supply Brand Name.
Is the product licensed in other Specify Country and
countries?
Location……………………………...
………………………………………..
Y
N
In the product for re-export?
If yes, supply details:……………….
Will it be re-processed and
………………………………………..
repackaged? Yes
No
REMARKS
If No state date of first
application
Supply any other
information………………….
……………………………….
I ……………………………………………………. Citizen of……………………………………………......
and residing at………………………………………………………………………………………………….
Number, street, city, state, country
Hereby certify that this TAA- Pre-qualification form in three parts is duly completed in compliance
with the provision of Decree N0. 70 of 1979. I am duly authorized to furnish the foregoing
information and confirm that the said information is to my own knowledge, true and correct. I hereby
depose and say that I am perfectly aware of the said Decree and especially of the penalties therein
for tales statement.
Name…………………………………………………………….. Signature…………………………………
Company Stamp/seal
Date…………………………………..........