SUPPLIER REGISTRATION FORM

Section 1: Company Details and General Information

1. Name of Company:

2. Street Address: 3. P.O. Box and Mailing Address:

Postal Code: City:

Country:

4. Tel: 5. Fax:

6. Email: 7. WWW Address:

8. Parent Company (Full legal Name) :

9. Subsidiaries, Associates and/or Overseas Representative(s) - (attach a List if necessary):

10. Type of Business (Mark one only) :

Corporate/ Limited: Partnership: Other (specify):

11. Nature of Business:

Manufacturer: Authorised Agent: Trader: Consulting Company: Other (specify):

If you mark “Authorized Agent or “Trader”, please provide proof or certificate(s) from your manufacturer(s) that you are authorized to offer their products to the United Nations.

12. Year Established: 13. Number of Full-time Employees:

14 Licence no./Country where registered: 15. Have you previously registered or attempted to register with ESCAP?

16. Technical Documents available in:

English French Spanish Russian Arabic Chinese Other (specify)

17. Working Languages:

English French Spanish Russian Arabic Chinese Other (specify)

Section 2: Financial Information (Please attach a certified copy of recent balance sheet)

18. Annual Value of Total Sales for the last 3 Years:

Year ______: USD___________ Year ______: USD___________ Year ______: USD___________

19. Annual Value of Export Sales for the last 3 Years:

Year ______: USD___________ Year ______: USD___________ Year ______: USD___________

20. Bank Name: Swift/BIC Address:

Address:

21. Bank Account Number: Account Name:

22 Please attach a listing of reference sources for services rendered by your firm within the last 12 months. Please also indicate fax numbers

and contact person for your reference sources.

Section 3: Technical Capability and Information on Goods / Services Offered

23. Quality Assurance Certification (e.g. ISO 9000 or Equivalent) (please provide a Copy of your latest Certificate):

24. International Offices/Representation (Countries where the Company has local Offices/Representation):

25. For Goods only, do those offered for Supply conform to National/International Quality Standards?

Yes No

26. List below up to fifteen (15) of your Core Goods/Services offered:

Authorized agents and Traders must submit proof or certificate(s) from manufacturers that they are authorized to offer the products listed.

item(s )which are not accompanied by proof or certificate(s) from manufacturers will not be recorded in our supplier database.

UNCCS Code UNCCS Description (one Line for each Item) National/International Quality Standard

To which Item conforms

Please click here for UNCCS code listings UNCCS code.doc

Section 4: Experience

27. Recent Contracts with the UN and/or national government:

Organisation: Value: Year: Goods/Services Supplied: Destination:

USD

28. To which Countries has your Company exported and/or managed Projects over the last 3 Years?

Section 5: Other

29. Please list any current legal disputes in which your company may be involved.

30. List any national or International Trade or Professional Organisations of which your Company is a Member.

31. Certification:

I, the undersigned, warrant that the information provided in this form is correct, and in the event of changes details will be provided as soon as possible:

Name Functional Title

Signature Date

32. List of attachments