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ENROLLMENT FORM

I/ We _____________________ am/ are desirous of being enrolled on the list of Architect-cum-


Consultant for proposed development of plots at various locations in UP & Uttarakhand and
hereby apply for the enlistment. We give the following details for your consideration :

CATEGORY OF WORKS FOR WHICH APPLIED: __________________________________

Sl.No. QUERY ANSWER


1. Name of the firm
Proprietary / Corporate
2 Address OFFICE
RESIDENTIAL
3 i) What is the constitution of firm viz. Sole
Proprietor, Partnership, Pvt. Ltd., Public Ltd.,
etc.

ii) Enclose copy of partnership deed, Articles of


Association or Affidavit in case of sole
proprietorship as per Annexure A-1.
iii) Fill-in enclosed Annexure A-2 for
particulars of partners
4 PAN No.
TIN No.
VAT Registration No.
GST/Service Tax Registration No.
5 Registration with EPF and Details
6 Office Phone No.
Contact Residence Phone No.
Details Mobile No.
Fax No.
e-mail
7 Month and year in which the firm was
established in present name
8 Particulars of old firm (if present firm is new) if
main partners of the present firm were working
as architects, in some other name in the past
(The partnership deed of old firm be enclosed)
9 Particulars of sister construction firms, if any :
10 Fill and enclose Annexure B giving details of
enrolment with LIC of India in the past and
with other organizations
11 Has the applicant or his partners or Directors
been black listed in the past by any Central or
State Govt. Deptt./ Organization.
12 i) Annual Turn Over for last four years (Enclose YEAR Rs. in Lakh
the self attested Statement of Accounts of last i 2014-15
three consecutive years duly certified by ii 2015-16
Chartered Accountant with Registration
Number. iii 2016-17
ii) What evidence of proof is enclosed to
support the amounts of yearly turnover
iii) Enclose Income Tax Clearance Certificate
for last consecutive three years
13 i) Name and complete postal address of
bankers.
ii) NEFT and Bank Account Details Name of Bank:
Account No.
IFSC Code:
14 Fill in & upload Annexure-C giving full
particulars about major works completed during
past seven years

NOTE: List of only those works which are


similar in nature and carried out by firm
requesting for enrolment is to be given. Work
completion certificate for qualified projects
must be enclosed with address & contact
numbers of issuing authority
15 Work in Progress:
1) Whether full details of major work in hand
given in Annexure 'D' Note: The details
must be self attested..
2) Are copies of work orders for such large
works enclosed
16 Whether full information regarding permanent
technical staff employed given in Annexure 'E'
22 Any other information the applicant might like
to given
DECLARATION

I/We agree to notify the officer accepting this application and registering my/our names
on the list of Architect-cum - Consultants of Life Insurance Corporation of India, of any changes
in the foregoing particulars as and when they occur and to verify and confirm.

I/We understand and agree that the appropriate Life Insurance Corporation of India
Authority has the right as he may decide, not to issue tender form in any particular case and also
to suspend, remove or blacklist my/our name from Life Insurance Corporation of India list of
Architects in the events of my/our furnishing false particulars in the enroolment form or
submitting non-bonafide tenders or for technical or other delinquency in regard to which the
decision of appropriate Life Insurance Corporation of India Authority shall be final and
conclusive.

I/We certify that the particulars furnished in the enrollment forms are correct and that
should it be found that I/We have given a false certificate or that if I/We fail to notify the fact of
my/our subsequent amalgamation with another architect or firm, the Life Insurance Corporation
of India may disqualify my/our name from the list of enlistment.

PLACE:

DATE: Signature of Architect-cum-Consultant


AFFIDAVIT

(On Non Judicial Stamp paper of Rs. * ___________/ - in case the individual who is the sole
proprietor of the firm)

I .............................................................................................................................................
s/o ..................................................... age .......................... years, occupation business r/o
............................................................. do hereby state on oath as under:

That I am residing in ................................................................... locality of District


..................................................... since last ............................ years.

That I am the sole proprietor of a proprietary concern anme and sty le as


"........................................................" having it's office at.........................................................
District .............................. dealing in business of Government, civil contracts and ancillary
works attached therefore.

Hence this affidavit.

Deponent _____________

Note: This Affidavit should be notarized.


LIFE INSURANCE CORPORATION OF INDIA

CONSTITUTION OF FIRM - SOLE


PROPRIETORSHIP/PARTNERSHIP/LTD.CO./OTHER

DETAILS OF CONSTITUTENTS
Sr. Name of sole partner of Age Share Technical Experience Whether
No. Director/other High Year to As AS power of
Officials Year to Employee architect/ attorney
Holder
1 2 3 4 5 6 7 8

Signature of Architect - cum Consultant with Seal & Date


LIFE INSURANCE CORPORATION OF INDIA
PARTICULARS OF ENROLMENT WITH LIC AND OTHER ORGANIZATION
I.
Name of works for 1)
Which enrolled by 2)
L.I.C. in the past 3)
4)
Sr. Nos. for which tenders were submitted:
Sr. Nos. for which work-order was received:

II. ENROLMENT WITH OTHER ORGANISATIONS:

Sr. Name & Address of FIRST TIME LAST RENEWAL FOR ENROLMENT
No. Authority with whom ENROLMENT
you are enrolled Year Is copy Year to Class or Limit Is copy of
to of letter year Category (Rs. in letter
year enclosed Lac) enclosed
(1) (2) (3) (4) (5) (6) (7) (8)

Signature of Architect - Cum - Consultant with Seal & Date


LIFE INSURACE CORPORATION OF INDIA
LIST OF MAJOR WORKS COMPLETED DURING LAST FIVE YEARS
Sr. Name and Complete Postal Address of Order Value Comm Compe Penalty
No. Place of Owner Authority Ref. Cost of Is of work en- te ion levied for
Work & under whom No. & Project copy as per cement of delay of
Nature of work was Date (Rs. in enclo final bill of work competion,
Work carried Lac) sed (R"s. in work month if any
Lac) month years
Year
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

Note: Please ensure that teh complete postal address including Pin Code and Telephone /Fax
number/E-mail address etc are furnished under column No. 3 & 4 above.

Signature of Architect - cum - Consultant


with Seal & Date
ANNEXURE - D
LIFE INSURANCE CORPORATION OF INDIA
LIST OF WORKS IN HAND
Sr. Name of Complete Postal Address Order Date of Schedule Progress
No. Site of Work Own Authority Ref. Amount Is copy comme ed date made and
& Nature of er under No. & (Rs. in enclose n of expected date
Work whom Date Lac) d cement completi of comple
work was of work on of tion and
carried out work reasons for
delay, if any.
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)

Note: Please ensure that the complete address including pin code and Telephone /Fax number/E-mail
address etc are furnished under column No 3 & 4 above.
Signature of Architect -cum-Consultant with
Seal & Date
PARTICULARS OF PERMANENT TECHNICAL STAFF
Sr. Name Designation Age Academic Service with Details of Experience Year to
No. Qualification the Firm Year
(1) (2) (3) (4) (5) (6) (7)

Signatue of Architect -cum-Consultant with Seal & Date


ANNUAL TRUNOVER FOR LAST THREE YEARS.
S. Financial Total Contract IT certificate Audited balance sheet Remarks
No Year amount enclosed. Yes/No copy enclosed. Yea/No
received
(1) (2) (3) (4) (5) (6)
1 2014-15
2 2015-16
3 2016-17

Signature of Architect - cum- Consultant with seal & Date


ANNEXURE-G
PRE-QUALIFICATION BID CHECKLIST
Sr. Description of Enclosure Refer Item of form Uploaded Yes/No
No.
1. Partnership deed/Articles of
Association/Affidiavt (*) (*)
Annexure-1
2. Annexure (A-2) as supplied (Particulars of Partners)
3. Annexure-B (as supplied) (Particulars of enrolment in
LIC and other Organization)
4. Proof of Turnover
5. I.T.C.C. for last three years
6. (*) Annexure 'C' (as supplied) (List of major works
completed during last 5
years)
7. (*) Annexure 'D' (as supplied) (List of work in hand)
8. (*) Copies of work orders
9. (*) Annexure 'E' (as supplied) (Particulars of permanent
technical staff)
10. (*) Annexure 'F' Annual turnover for last
three years

Signature of Architect - cum - Consultant with Seal & Date