Vendor Information Form

Application for the Category

of:

Basic Information:
Name of Organization

Owner Name

Contact Person

Contact Address

Contact No Fax No

E-mail Address

Business Information:
Type of Company  Proprietorship  Partnership  Year of
Limited  Other Establish
Trade License No

BIN Registration No

e-TIN Registration No

Year of Experience

Major Client:
Name of Organization

Contact Person Contact Number

Name of Organization

Contact Person Contact Number

Name of Organization

Contact Person Contact Number

Name of Organization

Contact Person Contact Number

Name of Organization

Contact Person Contact Number

Bank Information:
Bank Name

Account Name

Account Number

Name & Address of

Bank Branch

Routing Number

Swift Code Number

Other Information:
If the answer to any of the following questions is yes, then please explain on a separate paper
Sl
Particulars Yes / No
No
I. Is the Company ever been bankrupt, or is in the process of being wound up?
II. Is the Company ever been alleged relating to payment of taxes?
III. Is the Company ever been involved with any money laundering, corruption, fraud,
any criminal or any other illegal activity?
IV. Is the Company ever been blacklisted or declared for breach of contract or any
dispute with any Government Agency, INGO or International Aid Organizations?
V. Is any representative of the Company having any relative worked with at one time or
another, or are presently employed with WaterAid Bangladesh?

Please submit the following documents together with this form:

Sl Sl
Document Document
No No
I. Company Profile (if any) II. Bank Solvency Certificate
III. Company Trade License IV. Price List (if any)
V. Articles of Incorporation, Partnership or VI. Certificate from Principal (Authorization,
Corporation (as applicable) Exclusive Distributorship/Agent etc.)
VII. Company BIN Certificate VIII. Experience Certificate/Copy of Contract
IX. Company e-TIN Certificate X. Available Facilities (Guest House/Venue)

Certification:
I certify that the above information is true and correct to the best of my knowledge and no material changes
have occurred to the business which would affect any of the above representations. Any misrepresentation
above may result in cancellation and severing all ties with WaterAid Bangladesh.

____________________
Signature & Date