Appendix

1. Application for Registration

2. Letter of Application for Bidding

3. Tax evasion pledge

4. Manufacturer’s Authorization

5. Letter of Technical Support

6. Curriculum Vitae

7. Certificate of Employment

8. Specification of Equipment <Refer to MS Excel Document>

9. List of Documents to be Submitted (SEALED ENVELOPE)

9-1. Application for Eligibility Examination

9-2. Self-evaluation for Eligibility Examination and Examination Table

9-3. Detailed Scores by Item

10. Bid Price Proposal <Refer to MS Excel Document> (SEALED ENVELOPE)

11. Building Layout <Refer to PDF Document>

12. Financial Accounting Report

13. Supply of Goods Plan (For Successful Bidder)

[Appendix 1 Application for Registration]

Application for Registration

To: President of KOICA KOICA Reg. No.

Name of Firm Taxpayer ID No.

Name of

CEO

ID No. of

Chief Executive

E-mail Homepage

Address of FirmTel. No.

Fax No.

Type of FirmPrivate Firm/

Corporation

Country in which Firm is

registered

Date of

Incorporation

Capital of FirmNumber of

Employees

Sales Records for past 3 years

Persons authorized

to sign Bids &

Contracts

Job Title Name Signature or Seal

Products

to be offered

Products Classification CodeSales Records

for past 3 years

Required

Documents ◦ Certificate of Taxpayer`s ID No. or Office Ownership

I, as a legally authorized representative of the Firm, duly state that all of the above information is true and correct and hereby duly apply for registration.

※ 1. Documents to be submitted must be issued or authenticated by Government Agency or authority concerned of the Applicant`s country, otherwise these documents must be certified by the notary public.

2. This application form must be filled out in English. When the original documents are in a language other than English, they must be accompanied by a duly notarized English translation.

Name of CEO Date

Signature or Seal

Name & Title of Applicant

E-mail :

[Appendix 2 Letter of Application for Bidding]

Letter of Application for Bidding1. Bidding and Bid Security

Bid Title Provision of Medical Equipment for National Pediatric Hospital in Phnom Penh, Cambodia

Invitation No. KOICA 2016-0000

Date of Submission of biddingdocuments and bid price July,25th, 2016

Application for Bidding (Name of Company) alone

Bid Security

UD $ ※ A bid security of five percent (5%) of your bid amount (Period: at least 30 days from date of submission of bidding documents and bid price )

2. Details of the Bidder

Section Name of Firm Address

Chief ExecutiveBidding Agent

Name Taxpayer ID No.

Representative Company (Seal) Name (Seal)

We apply for participating in the above Bid in accordance with Bid Documents including Bid

Instructions under International Guideline and Instructions on the International Bidding for

Equipment Provision

If the successful bidder fails to enter into the contract within the prescribed period of time, the bid

security deposited by the bidder shall belong to KOICA.

Attachment 1. Bid Security 1 copy

2. bidding documents and bid price, etc. 1 copy respectively

Company Name:

Chief Executive: (Seal)

Date :

Bid Security

Invitation No : KOICA-2016-0000Project Works : Provision of Medical Equipment for National Pediatric Hospital in Phnom Penh, CambodiaDate of Bid:

We, the undersigned, hereby guarantee that, if awarded a contract, we will perform faithfully the requirements of the contract.

(i) Should we withdraw our bid before its expiration and/or after being awarded by the Korea International Cooperation Agency (KOICA), or(ii) Should we refuse to conclude the contract, or(iii) Should we fail to establish a Contract Deposit in accordance with the contractual conditions,

We undertake to pay KOICA immediately an amount equivalent to five (5) percent of the total bid price, according to, and upon receipt of, its first written demand, without KOICA having to substantiate its demand.

We further guarantee that we will not claim against or appeal to KOICA in relation to any unfavorable action which may be taken against us by KOICA on the grounds that we have not complied with the above conditions.

Signed on , 20yy

Contractor: by [ Signature ] Name: Title: Guarantor: by [ Signature ] Name: Title:

* A different form of security is acceptable to KOICA only when it is substantially equivalent to the form and substance of the security established by KOICA herein.

[Appendix 3 Tax evasion pledge]

Tax evasion pledge

1. We undertake full understanding and compliance of “Article 27-5 of ACT ON CONTRACTS TO

WHICH THE STATE IS A PARTY” and “Article 12 of the ENFORCEMENT DECREE OF

THE ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY“. We declare that neither

we nor any other party acting on our behalf with regard to the Project has engaged or will engage

in corrupt or fraudulent practices.

<Reference: Article 27-5 of ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY>

(Article 27-5) Restriction, etc. on Qualification for Participation of Inappropriate Business Entities in Tendering

Procedures

A person for whom there is a request by the Fair Trade Commission to restrict the qualification of participating

tendering, due to the violation of the Monopoly Regulation and Fair Trade Act or the Fair Transactions in

Subcontracting Ac

<Reference: Article 12 of ENFORCEMENT DECREE OF THE ACT ON CONTRACTS TO

WHICH THE STATE IS A PARTY>

(Article 12) Qualifications for Participation in Competitive Tendering Procedures

A person for whom there is a request by the Fair Trade Commission to restrict the qualification of participating

tendering, due to the violation of the Monopoly Regulation and Fair Trade Act or the Fair Transactions in

Subcontracting Act.

2 According to the above, we have to submit evidence in accordance with Article 2 (5) of the ACT

ON THE LAPSE OF CRIMINAL SENTENCES, however difficult it may be to do so. We hereby

confirm the following are not applicable.

PUNISHMENT OF TAX EVADERS ACT

Article 3 (Tax Evasion): A person who evades a tax of at least 500 million won.

CUSTOMS ACT

Article 270 (Offense, etc. of Evading Customs Duties): A person who has his/her custom duties imposed on personal goods that are reduced or exempted by any illegal means or that evades the collection of customs duties on goods for which customs duties have been reduced or exempted at least 500 million won.

FRAMEWORK ACT ON LOCAL TAXES

Article 129 (Evasion of Local Taxes): Any person who evades a local tax or obtains a refund or deduction thereof by deceit or other fraudulent means by at least 500 million won.

ADJUSTMENT OF INTERNATIONAL TAXES ACT

Article 34-2 (Penalty Provisions Applicable to Non-Fulfillment of Obligation to Report on Overseas Financial Accounts): Where a person is liable to report on information on his/her overseas financial account under Article 34 (1) fails to report within the reporting deadline, or under-reports the amount (hereafter referred to as "amount in violation of the liability to report" in this Chapter) exceeds five billion won.

FOREIGN EXCHANGE TRANSACTIONS ACT

Article 18 (Reporting, etc. on Capital Transactions): Any person who intends to perform capital transactions, and

Article 29 (Penalty Provisions): Any person whose amount from a violation of an obligation to report under Articles 16 or 18 has exceeded the amount prescribed by Presidential Decree within the extent of not less than five hundred million won

If the above statement is different from the fact, we confirm that we could receive sanction disposition as improper business in accordance with Article 76 of the "ENFORCEMENT DECREE OF THE ACT ON CONTRACTS TO WHICH THE STATE IS A PARTY" and the termination of contract

Date:

Name: (sign)

[Appendix 4 Manufacturer’s Authorization]

Manufacturer’s Authorization

[The Bidder shall require the Manufacturer to fill in this Form in accordance with the instructions

indicated. This letter of authorization should be on the letterhead of the Manufacturer and should be

signed by a person with the proper authority to sign documents that are binding on the

Manufacturer]

Date: [insert date (as day, month and year) of Bid Submission]

To: [insert complete name of Purchaser]

WHEREAS

We [insert complete name of Manufacturer], who are official manufacturers of [insert type of goods

manufactured], having factories at [insert full address of Manufacturer’s factories], do hereby

authorize [insert complete name of Bidder] to submit a bid the purpose of which is to provide the

following Goods, manufactured by us [insert name and or brief description of the Goods], and to

subsequently negotiate and sign the Contract.

We hereby extend our full guarantee and warranty in accordance with Clause 18 of the General

Conditions of Contract, with respect to the Goods offered by the above firm.

Signed: [insert signature(s) of authorized representative(s) of the Manufacturer]

Name: [insert complete name(s) of authorized representative(s) of the Manufacturer]

Title: [insert title]

Duly authorized to sign this Authorization on behalf of: [insert complete name of Bidder]

Dated on day of , [insert date of signing]

[Appendix 5 Letter of Technical Support]

Letter of Technical Support

To: President of Korea International Cooperation Agency.

Project: Provision of Medical Equipment for National Pediatric Hospital in Phnom Penh,

Cambodia

We hereby commit that we, the company, will designate at least three(3) qualified staffs in project

site(National Pediatric Hospital in Phnom Penh, Cambodia) for technical support such as quickly

the demand of repair and replacement of the goods during the deflect repair period(for 2 years)

20 . . .

Address :

Company:

Representatives: (Seal)

[Appendix 6 Curriculum Vitae]

Curriculum Vitae

Full NameAddress:

Telephone: (Mobile) Email:

LANGAUGE SKILL(Sample)▪ Khmer : Native

▪ English : Good

EDUCATION AND TRAINING (Sample)▪ 1999: Certificate of high school

▪ 2004: Bachelor degree of Business Administration at National University of Management (NUM) in major

Management information system(MIS)

- Business English, Principle of Accounting, Principle of publish relation, Principle of management and Principle of

communication.

- E-commerce, Computer system, A+ Certificate, Computer Literacy, Troubleshooting, Word Processing, Adobe

Pagemaker6.5, Auto CAD R14, math in Computer, HTML, JAVA Script

▪ 2008: Certificate of GE Healthcare (Life support )Engstrom Ventilator machine for service training at Cambodia

▪ 2009: Certificate of GE Healthcare (Life support )Engstrom Ventilator machine for service training at Philippine

▪ 2011: Certificate of Effective Communication skill

▪ 2012: Certificate of GE Healthcare (Life support ) Anesthesia machine for service training at Malaysia.

EXPERIENCE (Sample)▪ 2006: A Computer shop in major service, repair and maintenance

▪ 2008- 2016: A Medical Group Ltd in major service engineer

REFERENCE (Sample)▪ Mr. ABC

- Officer at Ministry of Health

- Tel: 855 12345687

- Email: ABC@abc.com

[Appendix 7] Certificate of Employment

Certificate of Employment

Date : [insert date (as day, month and year) of Bid Submission]

Name : [insert Full Name]

Sex : [insert Sex]

Date of Birth : [insert date (as day, month and year) of birth]

To Whom It May Concern.

This is to certify that [Insert Full Name] has been serving as a [Insert the Title] at [Insert complete

name of company] since [Insert date (as day, month and year) of employment]

Sincerely Yours.

Signed: [insert signature(s) of authorized representative(s) of the company]

Name: [insert complete name(s) of authorized representative(s) of the company]

Title: [insert title]

[Appendix 8] Specification of Equipment

Refer to MS Excel Document

[Appendix 9] List of Documents to be Submitted

List of Documents to be Submitted

(Those Documents (Appendix 9-1~3) should be sealed with Price Proposal)

Examinat

ion Area

Serial

No.Contents

Issuing Institution

(Certifying

Institution)

Remarks

General 1

2

3

Application for eligibility

examination

Self-evaluation for eligibility

examination and examination table

Detailed scores by item

Applicant

-〃-

-〃-

Attached Form 11-1

Attached Form 11-2

Attached Form 11-3

[Appendix 9-1] Application for Eligibility Examination (SEALED ENVELOPE)

(Attached Form 1)

Application for Eligibility Examination

ㅇ Public Notice No.:

ㅇ Name of Tender:

ㅇ Date of Tender:

I hereby submit the self-evaluation for eligibility examination and examination table and

other evidential documents, prepared in good faith, for eligibility examination relating to

the above tender to manufacture or purchase goods, and if it is confirmed that any of the

documents submitted has been prepared by fraud or other wrongful means, I hereby

pledge not to raise any objections to handling of this case in accordance with the

Eligibility Examination Criteria of the Korea International Cooperation Agency, the

Regulations on Contracts and Procurement relating to Foreign Grant Aid and Cooperation

Programs, the Detailed Regulations of the same Regulations, and the Act on Contracts to

which the State is a Party.

Date Month Year

Bidder subject to Examination Address:

Company Name:

Representative: (Seal)

Attachments:

1. One copy of the self-evaluation for eligibility examination and examination table;

2. One copy of the detailed scores by item;

3. One copy of a certificate of delivery (sales) performance of goods, or a confirmation of delivery

(sales) performance of goods (limited to manufacture of goods);

4. One copy of a confirmation of credit ratings; and

5. Other accompanying documents (evidential materials for evaluation of credibility, etc.)

To the President of the Korea International Cooperation Agency

[Appendix 9-2] Self-evaluation for Eligibility Examination and Examination Table

(SEALED ENVELOPE)

(Attached Form 2)

Self-evaluation for Eligibility Examination and Examination Table

1. Goods subject to examination 2. Bidder subject to examination

Public notice

No. for

tender

Company

name (Tel.)

Representative

Date of tender

Business typeManufacturing( ),

Supply( ), Others ( )Product name

3. Personal information on the person in charge

of contact on behalf of the company

QuantityDepartment in

charge

Position

Bidding price

Name

Estimated

priceContact

number (Fax)

4. Comprehensive evaluation

(Unit: point)

Category Limits on point allocation

Self-evaluation score Examination score

Total 100

Management status 30

Tender price 70

Credibility 1

Grounds for disqualification -30

[Appendix 9-3] Detailed Scores by Item (SEALED ENVELOPE)

(Attached Form 3)

Detailed Scores by Item

Total score ( ) points

Type of business subject to

evaluation

Ⅰ. Management status: ( ) points

ㅇ Management status shall be evaluated according to "evaluation method by credit ratings,“ and

the detailed evaluation method applied shall be specified in attached Table 1-3.

Ⅱ. Tender price: ( ) points

Tender price (a) Projected price (b) Calculation: 70-2x│(88/100-a/b)x100│ Score

※ If a tender price below the projected price is at least 95.5/100 of the projected price, then the

score shall be 55 points.

※ The lowest score shall be 2 points.

※ However, an evaluation of the tender price shall be prepared by the Procurement and Contract

Team.

Ⅲ. Credibility: ( ) points

Examination Item Evaluation FactorLimits on Point

Allocation

Details of

GradeScore

Level of reliability

of quality control,

etc.

Technology

certification, etc.+ 3 points

Level of

conscientious

fulfillment of

contracts

Delayed delivery,

etc.- 2 points

[Appendix 10] Bid Price Proposal (SEALED ENVELOPE)

Refer to MS Excel Document

For Bid Price Proposal and detailed price statements in MS Excel Document, paper and CD

must be submitted in sealed envelope

[Appendix 11] Building layout

Refer to PDF document

[Appendix 12] FINANCIAL ACCOUNTING REPORTS IN RECENT YEAR (2015)

DESCRIPTION 2015 Remark

Total assets

Total sale

Equity capital

Current Liabilities

Fixed Liabilities

Current assets

Net profit

Cost of sales

Net profit to net worth ratio Net profit/Equity capital

Debt ratio Total liabilities/Equity capital

Liquidities ratio Current assets/Current liabilities

Equity ratio Equity capital/Total capital

※ Notice

○ 01 Copy of latest Statement of Account (Balance sheet, Statement of profit and loss) should be attached.

○ All certificates and confirmations must be submitted after the date of announcement.

- In case of no alteration, all submitted documents must be certified copies.

[Appendix 13] Supply of Goods Plan (For Successful Bidder)

Supply of Goods Plan

( Name of Project )

DD/MM/YYYY

Name of Company :

1. General Information (Details of supplies and procurement

method)

※ Replaced by the specification (MS Excel form) of Appendix 8.

- Every entry must be filled out completely in Excel and no modifications are allowed.

□ Notes

○ Persons participating in an inspection must be a contractor. If manufacturer

representative participates, the responsibility to comply with the contract remains

with the contracting party. Otherwise, it shall be regarded as an unfair inspection

and shall be warned in accordance with the relevant regulations.

○ The details of the goods (MS Excel) are confirmed to be equal to or more than the

specifications in the work instruction manual. If the items of delivery are changed

without prior approval from KOICA, the details will not be acknowledged

regardless of the reason.

- Documents such as the quality assurance certificate for equipment, strategic materials,

shipping reference documents, etc. must be provided before the inspection date.

Manuals, such as the manual accompanying the equipment, can be adjusted before

the inspection.

- The schedule of the supply plan should follow the delivery deadline on RFP, and must

be able to supply items that can meet the delivery deadline (To determine timely

timelines for procurement).

※ Items that have abnormal qualities (items that do not meet essential requirements /

relevant law permits) may be rejected, even if they submit quality assurance as

ready-made products.

* In the case of local purchases, the relevant tax is determined according to the tax law

of the country in question, Which takes this into consideration and keeping the bid

in mind. (Refer to the bid announcement)

2. Maintenance and Quality guarantee

* The duration of maintenance and warranty is the same as the contract conditions.

3. Supply Schedule

○ Schedule may be adjusted after notification to, and approval of, KOICA. Evaluated

upon individual circumstances, KOICA may not approve excluding terms of a

contract and schedule change.

- Any person responsible for supply schedule changes or delays that are not approved by

KOICA will be warned.

Contents of Work schedule Note

Date to submit Strategic material

judgmentWithin 00 days from the contract date

Within 1 month before delivery date(When you change the item, it will be submitted after inspection)

Domestic delivery (inspection application)

due dateWithin 00 days from the contract date

The inspection period is up to 7 days.Inspection schedules are planned in consultation with the supplier

Notification of Inspection

Notify 2 weeks before delivery date

Submit documents related to delivery

Within 7 days before delivery date In accordance with RFP

Delivery deadline (Domestic)

Within 00 days from the contract date* notify of delivery delay

Included in the warning of non-papers

Shipping Documents (Delivery List)Date to submit

Immediately after delivery* notify of shipment delay

Send KOICA and logistics companies

Submission of the Within 7 days from the request date of Check the Customs due date

dispatch plan(Local installation, etc.)

KOICA Discuss on the Contents of dispatch

Departure dateWithin 7 days from the request date of

KOICA* notify of departure delay

If there is an unavoidable reason, submit a statement of reasons

Start local installation(Including local

purchase)

If there is not an unavoidable reason at the time of arrival, recommendation of local

purchase and installation

When preparing the dispatch plan, submit date and details(Within DD/MM/YY)

Local installation andInspection application

date

Within 30 days from arrival (customs clearance day)

* notify of delivery delay

When preparing the dispatch plan, submit date and details(Within DD/MM/YY)

Maintenance planBilling after completion of local

installationPayment will be made after reviewing the contents

4. Person in charge of Project (At least one person from the

contractor)

Person in charge

Name (Job title or Position)

Phone Number

Office

Mobile

e-mail

Responsibilities

Second person in charge

Name(Job title or Position)

Phone Number

Office

Mobile

Responsibilities

5. Management Plan (Maintenance)

○ In the case of aid procurement equipment, a basic 2-year maintenance period (1 year

for software) is applied. Unless otherwise specified, it is the same as warranty period.

○ During the maintenance period, upon local or KOICA request requirements, a technical

support specialist should be dispatched and any expenses incurred are paid by

KOICA.

- Expected expenses will be supported on a case-by-case based on the directives of

KOCIA(Supported expenses: airfare, insurance, accommodation costs only)

- KOICA will review and approve the submitted maintenance plan. If KOICA approve it, the

contractor will dispatch an engineer. KOICA will settle the costs after reviewing the

outcome report.

※ The cost of maintenance is considered to be included in the cost of bidding. If KOICA

asks for additional maintenance after the maintenance period has expired the

contractor can proceed through a separate agreement.

Maintenance is a separate concept from the defect repair(Including warranty).This includes tasks of support for technical support after delivery and installation, as

well as replacement of consumables for required repairs. Support is offered through the maintenance of the period.

6. Planning for local purchasing and installation (training)

○ According to RFP, please describe the local purchase and installation (and training)

plan. Including

- When and how to buy locally.

- Local Installation Schedule (Customs clearance and dispatch plan)

- Other RFP instructions (optional)

Prohibit submitting by modifying the default form without discussion and confirmation of KOICA

and PMC. Additional instructions can be added to the task.