Volume for Submission Volume Three (3) Submission Contract Reference T00215PH Contract Title Standing List of Approved Providers for Pharmacy Based Public Health Services Maximum Period of Contract Six (6) Years Return Date Thursday 30 July 2015 Return Time 12:00 Noon Return To www.supplyingthesouthwest.org.uk Applicant Name Page 1 of 21
Volume for Submission 1 Organisation Information All Applicants are required to complete this section Name of the Organisation in whose the name the Contract will be awarded: Full Postal Address of the Organisation: Name of Main Contact(s) for this Contract: Telephone Number(s) for Main Contact(s): Email Address for Main Contact(s): Full Postal Address of the Organisation s Registered Office, if different from above: Company Registration Number (if applicable): Date of Registration: VAT Registration Number (if applicable): Company Registration Number of the Parent Company (if applicable): Date of Registration: Charities or Housing or other Registration number (if applicable): Please specify the Registering Body: Date of Registration: Full name(s) and responsibilities of Executive Directors/Partners/Trustees (please add extra rows if required): Name Responsibility Page 2 of 21
2 Service Interest All Applicants are required to complete this section 2.1 Please complete the three (3) tables below in respect of each of the Pharmacies you wish to register, providing details of: (a) days and hours of opening Table One (1); (b) Pharmacy facilities for providing the Services (e.g. discrete consultation room, screened area etc.) Table One (1); (c) the Services you will be able to provide at each of the locations listed. Applicants should note they do not have to offer the same Services at all of their Pharmacies Table Two (2); (d) whether the Applicant is interested in taking part in future pilots for additional Services. 2.2 Table One (1) Pharmacies Details Applicants should ensure the days of opening for each Pharmacy meet any specific requirements in respect of the Services the Applicant is seeking to provide. These details will be checked to ensure compliance with the days of opening requirements for the Services the Applicant is applying to deliver. Please insert additional rows if required. Pharmacy Name and Full Postal Address Days and Hours of Opening Pharmacy Consultation Facilities Page 3 of 21
2.3 Table Two (2) Service Interest Applicants should list each of the Pharmacies detailed in Table One (1) above and indicate by marking an X which of the Services they would like to provide from each Pharmacy. Please insert additional rows if required. Service Pharmacy Name EHC / Chlamydia Combined Consultation Chlamydia Grab-Box Service (Counter-top) Needle Exchange Supervised Consumption TB DOT 1 Smoking Cessation 1 TB DOT will only be commissioned from a Pharmacy also providing Supervised Consumption Please note Applicants may choose to offer just Supervised Consumption, but may not choose to offer just TB DOT. Page 4 of 21
2.4 Table Three (3) Service Pilots Question The Applicant confirms that they are willing to be part of any pilot that may be offered as part of future service development opportunities (for example Condom Distribution service via C-Card). Response Page 5 of 21
3 Selection All Applicants are required to complete this section 3.1 Grounds for Mandatory Exclusion Applicants are required to answer Yes or No to each of the questions in section 3.1.1 and 3.1.2 below. Each of the questions included shall be scored as Pass/Fail, where an Applicant responds No this will constitute a Pass. An Applicant that fails on one (1) or more of these questions may be judged to have failed at this Selection stage of the process in its entirety and may not be evaluated further. If you have answered Yes to question 3.1.2 on the non-payment of taxes or social security contributions, and have not paid or entered into a binding arrangement to pay the full amount, you may still avoid exclusion if only minor tax or social security contributions are unpaid or if you have not yet had time to fulfil your obligations since learning of the exact amount due. If your organisation is in that position please provide details using a separate Appendix. You may contact the Authority for advice before completing this form. 3.1.1 Within the past five years, has your organisation, Directors or partner or any other person who has powers of representation, decision or control been convicted of any of the following offences? (a) (b) conspiracy within the meaning of section 1 or 1A of the Criminal Law Act 1977 or article 9 or 9A of the Criminal Attempts and Conspiracy (Northern Ireland) Order 1983 where that conspiracy relates to participation in a criminal organisation as defined in Article 2 of Council Framework Decision 2008/841/JHA on the fight against organised crime; corruption within the meaning of section 1(2) of the Public Bodies Corrupt Practices Act 1889 or section 1 of the Prevention of Corruption Act 1906; (c) the common law offence of bribery; (d) (e) bribery within the meaning of sections 1, 2 or 6 of the Bribery Act 2010; or section 113 of the Representation of the People Act 1983; any of the following offences, where the offence relates to fraud affecting the European Communities financial interests as defined by Article 1 of the Convention on the protection of the financial interests of the European Communities: (i) the offence of cheating the Revenue; (ii) the offence of conspiracy to defraud; (iii) fraud or theft within the meaning of the Theft Act 1968, the Theft Act (Northern Ireland) 1969, the Theft Act 1978 or the Theft (Northern Ireland) Order 1978; (iv) fraudulent trading within the meaning of section 458 of the Companies Act 1985, article 451 of the Companies (Northern Ireland) Order 1986 Page 6 of 21
3.1.1 Within the past five years, has your organisation, Directors or partner or any other person who has powers of representation, decision or control been convicted of any of the following offences? (v) (vi) or section 993 of the Companies Act 2006; fraudulent evasion within the meaning of section 170 of the Customs and Excise Management Act 1979 or section 72 of the Value Added Tax Act 1994; an offence in connection with taxation in the European Union within the meaning of section 71 of the Criminal Justice Act 1993; (vii) destroying, defacing or concealing of documents or procuring the execution of a valuable security within the meaning of section 20 of the Theft Act 1968 or section 19 of the Theft Act (Northern Ireland) 1969; (viii) fraud within the meaning of section 2, 3 or 4 of the Fraud Act 2006; or (ix) the possession of articles for use in frauds within the meaning of section 6 of the Fraud Act 2006, or the making, adapting, supplying or offering to supply articles for use in frauds within the meaning of section 7 of that Act; (f) any offence listed: (i) (ii) in section 41 of the Counter Terrorism Act 2008; or in Schedule 2 to that Act where the court has determined that there is a terrorist connection; (g) any offence under sections 44 to 46 of the Serious Crime Act 2007 which relates to an offence covered by subparagraph (f); (h) (i) (j) money laundering within the meaning of sections 340(11) and 415 of the Proceeds of Crime Act 2002; an offence in connection with the proceeds of criminal conduct within the meaning of section 93A, 93B or 93C of the Criminal Justice Act 1988 or article 45, 46 or 47 of the Proceeds of Crime (Northern Ireland) Order 1996; an offence under section 4 of the Asylum and Immigration (Treatment of Claimants etc.) Act 2004; (k) an offence under section 59A of the Sexual Offences Act 2003; (l) an offence under section 71 of the Coroners and Justice Act 2009 (m) (n) an offence in connection with the proceeds of drug trafficking within the meaning of section 49, 50 or 51 of the Drug Trafficking Act 1994; or any other offence within the meaning of Article 57(1) of the Public Contracts Directive: (i) as defined by the law of any jurisdiction outside England and Wales and Northern Ireland; or Page 7 of 21
3.1.1 Within the past five years, has your organisation, Directors or partner or any other person who has powers of representation, decision or control been convicted of any of the following offences? (ii) created, after the day on which these Regulations were made, in the law of England and Wales or Northern Ireland. Non-payment of taxes 3.1.2 Has it been established by a judicial or administrative decision having final and binding effect in accordance with the legal provisions of any part of the United Kingdom or the legal provisions of the country in which your organisation is established (if outside the UK), that your organisation is in breach of obligations related to the payment of tax or social security contributions? If you have answered Yes to this question, please provide details below, and confirm whether you have paid, or have entered into a binding arrangement with a view to paying, including, where applicable, any accrued interest and/or fines? Comments in relation 3.1.2: Page 8 of 21
3.2 Grounds for Discretionary Exclusion The Authority may exclude any Applicant who answers Yes in any of the following situations set out in paragraphs (a) to (i); 3.2.1 Within the past three years, please indicate if any of the following situations have applied, or currently apply, to your organisation. (a) (b) (c) (d) (e) (f) (g) (h) (i) your organisation has violated applicable obligations referred to in regulation 56 (2) of the Public Contracts Regulations 2015 in the fields of environmental, social and labour law established by EU law, national law, collective agreements or by the international environmental, social and labour law provisions listed in Annex X to the Public Contracts Directive as amended from time to time; your organisation is bankrupt or is the subject of insolvency or winding-up proceedings, where your assets are being administered by a liquidator or by the court, where it is in an arrangement with creditors, where its business activities are suspended or it is in any analogous situation arising from a similar procedure under the laws and regulations of any State; your organisation is guilty of grave professional misconduct, which renders its integrity questionable; your organisation has entered into agreements with other economic operators aimed at distorting competition; your organisation has a conflict of interest within the meaning of regulation 24 of the Public Contracts Regulations 2015 that cannot be effectively remedied by other, less intrusive, measures; the prior involvement of your organisation in the preparation of the procurement procedure has resulted in a distortion of competition, as referred to in regulation 41, that cannot be remedied by other, less intrusive, measures; your organisation has shown significant or persistent deficiencies in the performance of a substantive requirement under a prior public contract, a prior contract with a contracting entity, or a prior concession contract, which led to early termination of that prior contract, damages or other comparable sanctions; your organisation: (i) (ii) has been guilty of serious misrepresentation in supplying the information required for the verification of the absence of grounds for exclusion or the fulfilment of the selection criteria; or has withheld such information or is not able to submit supporting documents required under regulation 59 of the Public Contracts Regulations 2015; or your organisation has undertaken to: (i) unduly influence the decision-making process of the contracting authority, or (ii) obtain confidential information that may confer upon your organisation Page 9 of 21
3.2.1 Within the past three years, please indicate if any of the following situations have applied, or currently apply, to your organisation. undue advantages in the procurement procedure; or (j) your organisation has negligently provided misleading information that may have a material influence on decisions concerning exclusion, selection or award. 3.3 Economic and Financial Standing The Authority may exclude any Applicant who answers No to any of the questions set out in paragraphs (a) to (c) or (d); 3.3.1 Do your organisations insurance policies meet the specified requirements for: (a) Employer s Liability Insurance - five million pounds ( 5,000,000) (b) Public Liability Insurance five million pounds ( 5,000,000) (c) Professional Indemnity Insurance Five million pounds ( 5,000,000) (d) (e) If you have answered no to any of the above will you meet the requirements by the Contract Start Date? You are required to provide copies of your current insurance certificates in respect of the Insurances listed at (a) to (c) above. Please confirm that you have provided copies of your current insurance certificates with your tender. If you are unable to provide copies of any the insurances listed at (a) to (c) please provide reasons below. Comments in relation 3.3.1 (e): Page 10 of 21
4 Award 4.1 Mandatory Criteria The questions within this section shall be assessed on the basis of pass or fail and applies to those questions that are able to be answered either as a Yes or No. The Authority s minimum requirement is for the Applicant to respond Yes to each question which relates to the Services which they are applying to provide. Applicants should respond N/A to any questions relating specifically to Services which they are not applying to provide. Applicants who respond No to one more or more of the questions within this section will be considered to have failed this section in its entirety and will be disqualified from the process. Question Number Questions Response 4.1.1 The Applicant confirms that each of the registered Pharmacies will have appropriately qualified and experienced Pharmacists and Pharmacy staff (including locums) in place on the Service Commencement Date, in order to deliver all of the Services they will be providing under this Contract. Applicants should refer to questions 4.1.10.1 to 4.1.10.6 for details of the specific requirements for each Service. 4.1.2 The Applicant confirms they agree to the rates set out in section 4.4.4 Pricing of Volume One (1) Instructions and Information in respect of each and all of the Services they wish to provide. 4.1.3 The Applicant confirms that they agree to the Post Award Selection Criteria as set out in section 4.4.3 Post Award Selection Criteria of Volume One (1) Instructions and Information. 4.1.4 The Applicant confirms that they will comply with the requirement to enter all activity data onto PharmOutcomes. 4.1.5 The Applicant confirms that where there is a change of Pharmacist and the replacement Pharmacist does not have the appropriate qualifications and experience to provide a particular Service, the Authority s Contract Manager will be notified immediately and that Service will be withdrawn from the Contract until such time as an appropriately qualified and experienced Pharmacist is in place. Page 11 of 21
Question Number Questions Response 4.1.6 The Applicant confirms they will undertake an audit of the currently employed Pharmacists and Pharmacy staff on the first anniversary of the commencement of the Service (and each subsequent anniversary thereafter), in order to ensure that each of its Pharmacies has the appropriately qualified and experienced staff in place to provide all of the Services which it has been approved to provide. 4.1.7 The Applicant confirms that they will provide the Authority s Contract Manager with the details of the outcome of the annual audit (as set out in 4.1.6 above) within five (5) working days of the completion of the audit. 4.1.8 The Applicant confirms that they will immediately notify the Authority and any materially affected parties (e.g. prescribing services in relation to supervised Consumption) should there be: (a) An unforeseen closure of the premises; (b) Changes to the configuration of the Pharmacy, either temporarily or permanently, that will have any effect on the delivery of a Service (e.g. addition or removal of consultation room); or (c) Changes to the ownership, whether in part or in full, of any of the Applicant s Pharmacies. 4.1.9 The Applicant, as employers, confirms that they will ensure that all Pharmacists and supporting staff are fit for the purposes for which they are employed i.e. suitably qualified and appropriately trained and vetted for the roles they are undertaking (for example DBS checks as per organisational requirements). For more information see: https://www.gov.uk/disclosure-barring-service-check/overview 4.1.10 Applicants are required to respond to questions 4.1.10.1 to 4.1.10.6 in respect of all of the Services. Where an Applicant is not applying to provide a particular Service they should select N/A. Applicants should note the Commissioner s expectations of assurance, in relation to questions 4.1.10.1 to 4.1.10.6, are as follows: (a) CPPE modules are to be the most recent, updated modules available to Pharmacists; (b) The Pharmacist is expected to be acting within their sphere of competence and adhering to professional guidelines; (c) Any requirements for SOPs to be in place require that they are both operational as well as fit for purpose by the date of commencement of the Contract; (d) Where there is a requirement for DBS checks these must be valid and appropriate to the employing organisation. Page 12 of 21
Question Number Questions Response 4.1.10.1 The Applicant confirms that all Pharmacists who will provide the EHC / Chlamydia Combined Consultation Service meet the following requirements: CPPE (a) Safeguarding children and vulnerable adults e-learning: https://www.cppe.ac.uk/programmes/l/safegrding-e-01/ (b) Safeguarding children and vulnerable adults (2015) e- assessment: https://www.cppe.ac.uk/programmes/l/safegrding-a-03/ (c) Emergency Contraception - e-learning: https://www.cppe.ac.uk/programmes/l/ehc-e-03/ (d) Emergency Contraception (2015) - e-assessment: https://www.cppe.ac.uk/programmes/l/ehc-a-07/ Optional CPPE modules (non-mandatory) (a) Sexual health in pharmacies e-learning: https://www.cppe.ac.uk/programmes/l/sexual-p-01/ (b) Sexual health in pharmacies (2015) e-assessment: https://www.cppe.ac.uk/programmes/l/sexual-a-07/ Local Training Appropriate Pharmacy staff undertake localised Chlamydia training as made available by the Commissioner. Other Relevant Criteria Requiring Self Declaration (a) All staff involved in the provision of EHC medication will sign the appropriate local PGD before commencing the service; (b) That staff supporting the Pharmacist (including locums) are competent to do so; (c) That the provision is within the Pharmacist s current sphere of competence; (d) The Pharmacy has appropriate premises for providing the Service in a discrete and confidential manner. / N/A Page 13 of 21
Question Number Questions Response 4.1.10.2 The Applicant confirms that all Pharmacists who will provide the Chlamydia Grab-Box Service (Counter-top) meet the following requirements: Local Training Appropriate Pharmacy staff undertake localised Chlamydia training as made available by the Commissioner. 4.1.10.3 The Applicant confirms that all Lead Pharmacists who will provide the Needle Exchange Service meet the following requirements: CPPE (a) Substance use and misuse (2nd edition, May 2012) e- learning: https://www.cppe.ac.uk/programmes/l/substance-p-02/ (b) Substance use and misuse - delivering pharmacy services (2015) e-assessment: https://www.cppe.ac.uk/programmes/l/substance-a-06/ Local Training Appropriate pharmacy staff undertake localised training as made available by the Commissioner. Other Relevant Criteria Requiring Self Declaration (a) That the pharmacy will be open to provide the service for a minimum of five (5) days a week; (b) That staff supporting the Pharmacist (including locums) are competent to do so; (c) That the provision is within the Pharmacist s current sphere of competence; (d) The Pharmacy has appropriate premises for providing the Service in a discrete and confidential manner; (e) The Pharmacy has appropriate premises for ensuring safe and appropriate storage of Needle Exchange equipment and paraphernalia; (f) The Pharmacy will have specified SOP s, which are fit for purpose, in place by the time of Contract commencement. / N/A / N/A Page 14 of 21
Question Number Questions Response 4.1.10.4 The Applicant confirms that all Lead Pharmacists who will provide the Supervised Consumption Service meet the following requirements: CPPE (a) Substance use and misuse (2nd edition, May 2012) e- learning: https://www.cppe.ac.uk/programmes/l/substance-p-02/ (b) Substance use and misuse - delivering pharmacy services (2015) e-assessment: https://www.cppe.ac.uk/programmes/l/substance-a-06/ Local Training Appropriate Pharmacy staff undertake localised training as made available by the Commissioner. Other Relevant Criteria Requiring Self Declaration (a) Pharmacies must provide a supervised consumption service Monday to Saturday unless the Pharmacy is contracted to be open seven (7) days a week, in which case the Service will also be available on a Sunday. The only exception to the six (6) day rule is where rurality is a factor, where a five (5) day opening (Monday-Friday) may be acceptable. The decision to accredit pharmacies who are open only five (5) days a week will be at the discretion of the commissioner. (b) That staff supporting the Pharmacist (including locums) are competent to do so; (c) That the provision is within the Pharmacist s current sphere of competence; (d) The Pharmacy has appropriate premises for providing the Service in a discrete and confidential manner; (e) The Pharmacy will have specified SOP s, which are fit for purpose, in place by the time of Contract commencement. / N/A Page 15 of 21
Question Number Questions Response 4.1.10.5 The Applicant confirms that all Pharmacists who will provide the TB DOT meet the following requirements: Other Relevant Criteria Requiring Self Declaration (a) The Pharmacy is already able to deliver Supervised Consumption Services (due to similarity of service provision); (b) That staff supporting the Pharmacist (including locums) are competent to do so; (c) That the provision is within the Pharmacist s current sphere of competence; (d) The Pharmacy has appropriate premises for providing the Service in a discrete and confidential manner. Please Note: This Service may only be provided in conjunction with Supervised Consumption Service and is only applicable to Torbay. 4.1.10.6 The Applicant confirms that all Pharmacists who will provide the Smoking Cessation Service meet the following requirements: CPPE Practitioners assessment - knowledge and skills: https://www.cppe.ac.uk/programmes/l/smoking-e-01/ Local Training Local Level 2 Adviser training Appropriate Pharmacy staff undertake localised training as made available by the Commissioner. Other Relevant Criteria Requiring Self Declaration (a) That staff supporting the Pharmacist (including locums) are competent to do so; (b) That the provision is within the Pharmacist s current sphere of competence; (c) The Pharmacy has appropriate premises for providing the Service in a discrete and confidential manner. / N/A / N/A Page 16 of 21
5 Certificates 5.1 TORBAY COUNCIL - CONDITIONS OF TENDER 1. Tenders are invited for the supply of the goods or services specified or described in the invitation. Tenders with conditions of contract duly completed and marked with the title of the Contract (as already stated on each of the Volumes for submission) and returned electronically via the Supplying the South West portal. Tenders must be returned by the date and time stated on the front page of Volume Three (3) Submission. Tenders received after the time stated or not properly completed will be disregarded. Facsimile and emailed copies will not be accepted. 2. The Contract shall be subject to the Authority s Conditions of Contract, included in these Tender Documents. Wherever special conditions of Contract are contained in the Invitation to Tender, the Contract shall be subject to those special conditions in addition to the Standard Conditions of Contract, and where those special conditions are inconsistent with the Authority s Standard Conditions of Contract, the special conditions shall prevail. Offers by Applicants made subject to additional or alternative conditions may not be considered and may be rejected on the grounds of such conditions alone. No alteration must be made to the printed conditions or schedules. Any Tenders bearing such alterations will not be considered. 3. The Authority does not bind itself to accept the lowest or any Tender, and reserves the right to accept a Tender either in whole or in part, for such item or items specified in the Invitation to Tender, and for such place or places of delivery as it thinks fit, each item and establishment being for this purpose considered as Tendered for separately. 4. To Torbay Council I/We the undersigned DO HEREBY UNDERTAKE on the acceptance by the Authority of my/our Tender either in whole or in part, to supply (or perform the services), on such terms and conditions and in accordance with such specifications (if any), as are contained or incorporated in the Invitation to Tender. I/We agree and declare that the acceptance of this Tender by letter on behalf of the Authority, whether for the whole or part of the items included therein, will constitute a Contract for the supply of such items, I/We agree to enter into a further agreement for the due performance of the Contract, and I/We declare that I am/we are acting as the Delegated Authority for the purposes of signing off this Tender, and therefore, the Contract. Signed*: Date: Name (in block capitals): In the capacity of: (State official position, i.e. Director, Manager, etc.) *(It must be clearly shown whether the Applicant is a limited company, statutory corporation, partnership or single individual, trading under his own or another name, and also if the signatory is not the actual Applicant, the capacity in which he/she signs or is employed). Page 17 of 21
5.2 CERTIFICATE OF UNDERTAKING AND ABSENCE OF COLLUSION OR CANVASSING The Applicant shall sign the below Certificate of Undertaking and Absence of Collusion. I/We the undersigned do hereby certify that:- (a) My/our Tender is bona fide and intended to be competitive and I/we have not fixed or adjusted the amount of the Tender by or under in accordance with any agreement or arrangement with any other person; (b) I/we have not indicated to any person other than the person calling for the Tender amount or approximate amount of the proposed Tender except where the disclosure in confidence of the approximate amount of the Tender was necessary to obtain insurance premium or other quotations necessarily required for the preparation of the Tender; (c) I/we shall have not entered into any agreement or arrangement with any other person that they shall refrain from Tendering or asked the amount of any Tender to be submitted; (d) I/we have not offered to pay or give any sum of money or valuable consideration directly or indirectly to any person for doing or having done or causing or having caused to be done in relation to any other Tender or proposed Tender for the said work any act or thing of the nature specified and described above. (e) I/we hereby certify that I/we have not and will not canvass or solicit any Member, Officer or employee of the Authority in connection with the preparation, submission and evaluation of this Tender or award or proposed award of the Contract and that to the best of my knowledge and belief, no person employed by me/us or acting on my/our behalf has done or will do such an act. (f) I/we further undertake that I/we will not do any of the acts mentioned in (d), (c) and (d) above before the hour and date specified for the return of the Tender Signed*: Date: Name (in block capitals): In the capacity of: (State official position, i.e. Director, Manager, etc.) *(It must be clearly shown whether the Applicant is a limited company, statutory corporation, partnership or single individual, trading under his own or another name, and also if the signatory is not the actual Applicant, the capacity in which he/she signs or is employed). Page 18 of 21
5.3 CERTIFICATE OF CONFIDENTIALITY I/we hereby agree with the Authority that I/we shall not at any time divulge or allow to be divulged to any person any information, confidential or otherwise, relating to information passed to me regarding this project. It is appreciated by the parties that in the event of negotiations in respect of the proposed Contract being entered into between the Authority and my organisation that it may be necessary to share information with colleagues within my organisation. In this event this confidentiality clause may be waived to allow such information sharing to take place but not further or otherwise. Signed*: Date: Name (in block capitals): In the capacity of: (State official position, i.e. Director, Manager, etc.) *(It must be clearly shown whether the Applicant is a limited company, statutory corporation, partnership or single individual, trading under his own or another name, and also if the signatory is not the actual Applicant, the capacity in which he/she signs or is employed). Page 19 of 21
5.4 PHARMACIST QUALIFICATION AND EXPERIENCE DECLARATION I / We declare that the Pharmacist(s) who will be employed in the delivery of the Services listed within section 2 Service Interest of this Volume Three (3) Submission, will meet all of the requirements in relation to the necessary qualifications and experience in accordance with the requirements of the Specification and all other tender documents. Signed*: Date: Name (in block capitals): In the capacity of: (State official position, i.e. Director, Manager, etc.) Organisation name and postal address: Telephone No: Fax No: *(It must be clearly shown whether the Applicant is a limited company, statutory corporation, partnership or single individual, trading under his own or another name, and also if the signatory is not the actual Applicant, the capacity in which he/she signs or is employed). Page 20 of 21
5.5 PRICING DECLARATION I / We offer to supply the Services as per the rates set out within Volume One (1) Instructions and Information in accordance with the Specification, terms and conditions and all other documents forming the Contract. Signed*: Date: Name (in block capitals): In the capacity of: (State official position, i.e. Director, Manager, etc.) Organisation name and postal address: Telephone No: Fax No: *(It must be clearly shown whether the Applicant is a limited company, statutory corporation, partnership or single individual, trading under his own or another name, and also if the signatory is not the actual Applicant, the capacity in which he/she signs or is employed). Page 21 of 21