Appendix 1
BACKGROUND INFORMATION QUESTIONNAIRE
Full legal name of Firm
Former Trading Name(s) (if any)
Address of registered office
Postcode
Telephone no.
Fax no.
Address of local office
(if different from above)
Postcode
Telephone no.
Fax no.
To whom should queries about this application be addressed?
Name
Telephone No.
Position
Ext.
Are you a:
Sole Trader?
Private Ltd. Company?
Other (please specify)
Yes
Yes
Yes
No
No
No
Partnership?
Public Ltd. Company?
Date business commenced
If limited, give registration
Date
Where registered
If unlimited give name and address of proprietor(s)
Name
Name
Address
Address
Postcode
Postcode
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Yes
Yes
No
No
Or details of deed partnership
Brief description of the firm’s main business:
In the field to which this application refers, how long has your firm been carrying
on business?
years
Is the firm a member of a group of companies?
Yes
No
If “Yes”, give details of the ultimate holding company and all other subsidiaries.
Name of ultimate holding company
Address of Registered Office
Telephone no.
Fax No.
Will the group or ultimate holding company be prepared to guarantee your contract
performance as its subsidiary?
Yes
No
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Give name(s) of all subsidiaries
Name
Address
Relationship
Nature of business
Name
Relationship
Address
Nature of business
Give name(s) and address(es) of trade association (s) of which the firm is a member
(including any accountancy body with which the firm is a registered auditor).
Name
Address
Name
Address
Name
Address
Name
Address
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Give details of all Directors, Partners, associates or Company Secretaries
Name
Position
How long?
Name
Position
How long?
Name
Position
How long?
Name
Position
How long?
Has your firm or any of the Directors, Partners or Associates been declared bankrupt, has
made a composition or arrangement with its creditors, has had a winding up order made, a
resolution for voluntary winding up passed, a proposed liquidator, receiver or manager
appointed, an administration order made?
Yes
No
If “Yes”, give details
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Has your firm or any Director, Partner or Associate been found guilty of any civil or criminal
action(s) taken by any individual or organisation, including the Inland Revenue, HM Customs
and Excise, Department of Health, Social Services and Public Safety, or any other Government
Department?
Yes
No
If the answer to the above question is “Yes”, please give details.
Public Liability (third party) Insurance held.
Insurer
Policy Number
Extent of cover
Expiry date
Employers Liability Insurance held.
Insurer
Policy Number
Extent of cover
Expiry date
Professional Liability Insurance held.
Insurer
Policy Number
Extent of cover
Expiry date
The NIAO reserves the right to request copies of your insurance certificates.
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Is your firm unqualified* within the meaning of the legislation in Northern Ireland in relation
to Fair Employment?
Yes
No
* Section 62 of The Fair Employment and Treatment (Northern Ireland) Order 1998 refers. An employer may be
served a notice from the Fair Employment Commission because they have defaulted on the legislation and if that
notice has not been cancelled it renders the employer ‘unqualified’.
Has your firm been found guilty in law, of breaches under
Equal Opportunities
Or Health and Safety Legislation
Yes
Yes
No
No
Yes
No
Are there any outstanding claims or litigation against your firm?
If “yes”, please provide details on a separate sheet.
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After completion of the questionnaire please read and sign the section below:
I/We certify that the information given is accurate to the best of my/our knowledge.
I/We understand that false information could result in the termination of any future contract
awarded.
I/We understand that it is a criminal offence to give or offer any gift or consideration
whatsoever as an inducement or reward to any employee of an NI Public Sector body and
that any action will empower the contracting authority to cancel any contract then currently
in force and will result in my/our exclusion from any further contract award.
I/We certify that no member, officer or employee of the NI Public Sector has been canvassed
or solicited in connection with this application.
I/We certify that I/we have not colluded with other firms tendering for the contract.
I/We further agree that if awarded a contract I/we shall permit the contracting authority,
Crown servants or agents at all reasonable time to enter any of my/our premises for the
purpose of inspection and investigation of the employment, social security and tax records of
any person engaged to carry out any works under the contract.
In addition I/we undertake:
-
that any changes in the information included in this application will be
notified in writing within 7 days of the event;
-
that any tender submitted in respect of NI Public Sector contracts will
be wholly bona fide and my/our tender price(s) will not be divulged to
any person or body of persons before the time and date specified for
the return of tenders.
I/We confirm acceptance of NIAO Standard Terms and Conditions at Appendix 5 of this ITT
and agree to abide by these Terms and Conditions which take precedence over any terms,
conditions, stipulations or provisos which may appear on or be annexed to any
correspondence submitted by the tenderer in connection with this Contract.
I/We confirm that this tender shall remain open for acceptance by the NIAO for a period of
90 days after the due date for the return of tenders specified.
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Signed
in the capacity of
Name (Block Capitals)
Duly authorised to sign for and on behalf of
Date
To be signed by an authorised representative in his/her own name and on behalf of the firm.
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