FSTO-01

As on Date : _________

“Vendor Evaluation Form”

To ,
Grasim Industries Limited Addressed to
Materials Management Dept

Details of Vendor
Contact Information (Please fill in BLOCK letters only):

1. OFFICE ADDRESS
NAME 1 : (30 CHR )
DAUTSONS INFRATECH INDIA PVT. LTD.
NAME 2 : (30 CHR )

STREET 1: ( 35 CHR )
ROYAL TRADE CENTRE , PAL AREA
STREET :2 ( 35 CHR )

STREE-HOUSE NO : ( 60 CHR )
OFFICE NO 602
PIN CODE : (6 CHR)
395009
CITY : (35 CHR)
SURAT
GUJARAT
STATE :

WEB SITE
WWW.DAUTSONS.COM
CONTACT DETAILS First Person Second Person
MR. PUNEET SAINI MR. SAMRAT
NAME OF PERSON(S)

DESIGNATION
GENERAL MANAGER MANAGER
MOBILE NO.
+91-7722079047 +91-9925432579
STD CODE

PHONE NUMBER 1 : ( 30 CHR) WITH EXTN

- -
PHONE NUMBER 2: ( 30 CHR) WITH EXTN

PHONE NUMBER RESIDENCE: ( 30 CHR)

FAX : ( 30 CHR )
2. WORKS ADDRESS of Factory / Place of Delivery

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STREET 1: ( 35 CHR )

STREET :2 ( 35 CHR )

STREE-HOUSE NO : ( 60 CHR )

PIN CODE : (6 CHR)

CITY : (35 CHR)

STATE :
CONTACT DETAILS First Person Second Person
NAME OF PERSON(S)

DESIGNATION

MOBILE NO.

STD CODE

PHONE NUMBER 1 : ( 30 CHR) WITH EXTN

PHONE NUMBER 2: ( 30 CHR) WITH EXTN

PHONE NUMBER RESIDENCE: ( 30 CHR)

FAX : ( 30 CHR )

EMAIL :
3. Office Premises (Please tick ) : Ownership Rental

Factory Premises (Please tick ) : Ownership Rental

4 Type of firm: Proprietor Pvt. Ltd. Public Ltd Contractor
(Tick)
5 Type of Activity Manufacturer Dealer Trader EPCM JOBS
(Tick)
6 Nature of 1 EPCM SERVICES
items /
Services : - 2 CHEMICAL SERVICES

7. Product / Service Range: -

8 Name Name & Place Dealing in :

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 of DAUTSONS CHEMICAL RESOURCES CHEMICAL SUPPLY
your (GUJARAT)
Sister DAUTSONS HEAVY ENGINEERING TECHNOLOGICAL AND EQUIPMENT
concerned/ (GUJARAT) FABRICATION
associations VIRGIN TECHNIBUIL INDIA PVT LTD PILING AND CIVIL JOBS
(INDIA )
9 Name of Companies yours firms is having authorized dealership
(Pl. enclose copy of Certificate from OEM / Principal Vendor)

Name and Address of company Name of Products

1
2
3
Enclose list of Supply Order of last one
10 Major Existing Customers
year
Customer Name Product / Service Volume of Business
MECH. 1 CR
1 GUJARAT FLUORO CHEMICALS FAB&EREC

2 ESSAR STEEL CIVIL JOBS 10-12 CR

3 TATA PROJECTS LTD PILING ,CIVIL 50 CR

4 INDIANA CONVEYORS MATERIAL 50 LAKHS

HANDLING &
CONVEYING
SYSTEMS

11. List of Supplies to Aditya Birla Group Enclose list of Supply Order of last one
year
Name of Unit Product / Service Volume of Business
Supplied
1 PRESENTLY APPROACHING

12. Provide the details : Name of sub-dealer, nearest service representative, channel partner for after
sales service :

13. Value of Stock as on Date :

14. Nos. of Machines/ equipments installed for the product supplied : 13 PILING RIG , CRANE , HYDRA
AND ALL TOOLS TACKLES
15. Testing facility & quality control : ALWAYS ARRANGED AT SITE

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16. Man power employed : 50

17. Financial Status (Enclose Balance Sheets) Previous Year Current Year
Value of Assets
50 CRORES 50 CRORES
Turnover 30 CRORES 10 CRORES
Profit 2 CRORES 0.8 CRORES
18. Whether you are having well defined Quality  IS / ISO 9001 : 2008
Management System / whether your firm is  ISO14001
Registered with ISO / BIS  SA-8000
If yes, please specify details. i.e., code no. validity  OH&SAS-18001
& enclose copy  ANY OTHER

19. Factory Licence/Registration no. -

20 Specify Local / Social obligations if any : -
21. Tax related Data
ECC Number & DATE

Import Export Code (IEC)

Excise Registration Number

Excise Range

Excise Division

Excise Commissionerate

Tariff Classification

SSI Status (Attach photocopy compulsorily)

15 DIGIT GST ID (Attach photocopy compulsorily)

CST No. & DATE (Attach photocopy compulsorily)

MPCT Number & DATE

VAT/LST No. (Attach photocopy compulsorily )

PAN No. (Attach photocopy compulsorily) AAGC1740H

TIN Number (Attach photocopy)

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 Despatch Location wih TIN No.
Important Note : address
Provide the TIN numbers of all your dispatch locations in
order to issue correct ‘C’ form for interstate sales. In
case your correct TIN number is not registered with us,
Grasim will not be responsible for issue of ‘C’ forms.
TAN Number
Service Tax Registration Number
(Attach photocopy compulsorily)

22. Bank Name

Bank A/c Number

(ATTACH COPY OF CANCELLED CHEQUE)
Type of Account (Saving / Current)
Location (City) of bank
Bank branch address
MICR code of bank
Bank branch computerized / IFSC CODE (Compulsory) Yes / No
Branch Real Time Gross Settlement enabled Yes / No
Branch electronic data transfer / electronic fund transfer Yes / No
enabled
Email address

23. Documents to be enclosed by vendor

sr Particulars Remarks if any
1 Request for registration
2 Balance sheet as per item no. 17
3 Electricity bill /telephone bill of Office and Factory premises
4 Authorized dealership certificate as per item no. 9
5 Copy of Purchase / Service order as per item no. 10 & 11
6 Copy of registration as per item no. 17 to 21
7 Bank details along with Cancel Cheque as per item no. 22
8 Whether your firm covered under MSMED Act  YES (Please attach MSMED Act
Certificate)
 NO
 RELATED PARTY
Whether vendor is related party or related to any of employee
9  EMPLOYEE
/ director of company
 DIRECTOR OF COMPANY

Other informations

A. Basic Information
No. of Employees Staff Workmen Total
I Permanent
II Casual
III Badli
IV Contracted

B Information regarding Social Accountability / Safety

1 Minimum age (Years) is required to join your Organization ? 18 years
2 Do you keep original certificates (like mark sheet, Passport) or Yes
deposit of cash at the time of employment ?
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3 Do you provide safe & healthy work environment as per Yes
statutory requirement (Factory Act 1948) ?
4 Do you have dispensary and ambulance room / First Aid free of Yes
cost ?
5 Do you have canteen facilities for your employees ? No
6 Do you have drinking water facilities for your employees ? Yes
7 Do you have separate toilet facilities for your male & female Yes
employees ?
8 Do you have Trade Union/Association in your organization ? Yes / No
9 What are the procedure of hiring / promotion / remuneration in Three
your organization ? level
interview
and tied
up with
agency
10 Are you covered under Industrial Employment (standing order) Yes
Act 1946 ?
11 Do you have a written Safety Policy ? Yes
12 Does executive management review safety performance ? Yes

13 Has the company had a local safety authority inspection in the Yes
last 3 years ?
14 Do you have a safety manual, Safety management system ? Yes
15 Are the employees insured ? Yes
16 Do you give safety training to all personnel working on the job ? Yes
17 Do you conduct Medical Checkup of your employees ? Yes
18 Do you hold Safety Meetings ? Yes
19 Do you perform risk assessments and method statements ? Yes
20 Do you obtain safety work permit before starting work ? Yes
21 Do you have sufficient resources (equipment / staff) to complete Yes
the work safely ?
22 Do you provide personal protective equipments to your Yes
personnel on the job ?
23 Do you deploy adequate safety professionals for job execution ? Yes
24 Do you comply to the safety expectations ? Yes
25 No. of shifts you have ? Two
26 What is the lowest amount you pay to your employees (1)
(1) More than minimum wages
(2) As per Minimum Wages Act
(3) Less than min. wages as per Minimum Wages Act

(Please attach Documents (may be Photograph of area concerned, copy of salary slip,
registers, records etc. in supporting to all above statements.)

I hereby declare that my organization is committed to adhere to

Quality, Safety & Social Accountability Standards of your
organization.

I further declare that the above mentioned information are

correct.

Signature of CEO / OWNER /PARTNER & STAMP

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 Vendor Evaluation Form

FOR GRASIM OFFICE USE ONLY

Rating for (out of 5)

Reliability Creditworthiness Sustainability

Credentials

REMARKS BY PURCHASE DEPT.

1. Techno-commercial visit to evaluate existing facilities at Vendor's end. – Required / Not

Required

2. Quality Parameters acceptability by Unit – Yes / No

3.

4.

Checked by Approved by Authorized by

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