S Karnataka H,*+htl$,
Office
Circle
Kankanady
Mangalore -5750O2
Regd. & Head
P. B. No.599, Mahaveera
Phone :0824-2228222Fax:0824-2225589
E-mail :[email protected]
Web site:www.karnatakabank.com
CIN
:185110KA1924PLC001128
TREASURY & ACCOUNTS DEPARTMENT
November 24,2014
Application no.LBL,/BNG/0'L/201.4-15 (No. of Pages
5)
DD (for Rs.1500/- non-refundable favouring Karnataka Bank Ltd.,drawn on Mangalore)
NO. With date:.
DD issued Bank & Piace...
APPLICATION FORM FOR EMPANELMENT OF CIVI CONTRACTORS FOR
CONSTRUCTION OF BANK'S ONA{ COMMERCIAL BUILDING IN BANGALORE.
{The proposed building to be constructed is at Bull Temple Road,Bangalore comprising of Basement(Car parking)
+Ground + 3 Upper floors with an approximate cost of Rs.7 to 8 crore with total area of around 28,800 Sft on
vacantLand of size 70 feetx 130 feet)
SL
DESCRIPTION
PARTICULARS
NO.
1
Name of the Organisation
2
Name of the Head of the Orsanisation
Address
J
4
5
6
7
Telephone Number
Fax Number
Cell number
Year of Establishment
Status/constitution of the firm (whether
comnanv / Partnershin / oroprietarv)
Name of the
Directors/ Partners/ Proprietor
i)
ii)
iii)
it)
v)
vi)
with the registrar of
8
\zVhether registered
9
companies/the registrar of Firms
If yes-Registration number and date
(Enclose relevant copies as proof).
a) Name and address of Bankers:
0
i0
iii)
ir)
v)
10
11
b) Enclose solvency certiJicate from the
Bankers
Whether registered for sales tax
purposes.
If yes, number and date
(Enclose relevant copies as proof).
V\rhether an assessee of Income taxes?
If yes, furnish Permanent Account No.
(Enclose relevant copies as proof).
Pagel of
SIGNATURE OF THE CONTRACTOR WITH SEAL
5
DESCRIPTION
SL
PARTICULARS
NO.
12
13
Furnish copies of-Audited Balance sheet
-Audited profit & Loss account
(audited) for the last 3 years.
(Enclose relevant copies as proof).
If you are registered in the panel of
other organizattons/Statutory bodies
such as CPWD.PWD, MES, Banks etc,
furnish their names, category and date
of
14
15
1.6
17
registration
with
copies. (Enclose
relevant copies as proof).
Detailed description and value of works
executed in the past.
-For Banks
-For others
(Enclose relevant copies as proof).
Specify the maximum value of work
executed in a year (enclose relevant
copies as proofl.
Furnish the names of three responsible
i)
persons who will be in a position to
ii)
certify about the quality as well as past
iii)
performance of Organisation along with
contact numbers
Furnish additional information in
Annexure L,2 and 3
Note:
1) Where copies are required to be furnished, they are to be certified copies by the concerned
agencies or a Government officer.
2) Filied above application in seaied cover super scribing " Applications for empanelment of
Civil Contractors" shall be submitted to the under signed on or before 15/12/2014 durrng office
hours.
3) The right to reject any or all the application without assigning any reasons is reserved with
the undersigned & Bank reserves the right to accept, negotiate, reject or to relax the qualifying
requirement, if necessary ,in its own interest and the decision of the Bank in this regard is final.
Place:
Date:
SIGNATURE OF THE CONTRACTOR WITH SEAL
-sdDEPUTY GENERAL MANAGER
THE KARNATAKA BANK LIMITED
TREASURY & ACCOUNTS DEPARTMENT
HEAD OFFICE, P.B.NO.599, MAHAVEERA CIRCLE,
KANKANADY, MANGALORE-575002
Page 2 of 5
ANNEXURE.l
PARTICULARS
Proiect-1
Proiect-2
Proiect-3
Proiect-4
Short description of
works executed
Value of
project
each
Woks
carried out
(plumbing &
Electrical works rt
ar
y to be shown
in the
separately
same column)
Rs.
Commencement
&
Finishing date
of Proiect work
Name of the
consultants
Note: For more No. of projects separate sheet in the above format may be enclosed
SIGNATURE OF THE CONTRACTOR WITH SEAL
Page 3 of 5
ANNEXURE -2
KEY PERSONNEL PERMANENTLY EMPLOYED
SL
Name
Designation
Qualification Experience
NO.
Years
Any other
with the Information
firm
not included
1
2
a
J
4
5
6
7
8
9
10
SIGNATURE OF THE CONTRACTOR WITH SEAL
Page 4 of 5
ANNEXURE -3
OTHER RELEVANT INFORMATION
Name
SL
NO.
1
Carpenters
2
Helpers
J
Masons
4
Electricians
5
Plumbers
6
Others
No. Of Years
with the firm
Any other
Information
not included
WORKSHOP FACILITIES:
SI
No
Type Of
Structure
Land Area
and Place
Type of
Facilities
Total
Value
of
Whether
Owned/Leas
e/Rent
Workshop
Rs.
1.
2
List Of Major
Equipments
Possession Of The Firm
A)
B)
c)
D)
E)
F)
G)
H)
D
r)
SIGNATURE OF THE CONTRACTOR WITH SEAL
Page 5 of 5