registration form

(CA Ref.: UAJ22 (Phase 2))

  1. Contact Information
    1. Company Name:                                                                                                                                            
    1. Contact Persons (please name 2 persons in charge):
NameTitle / SectionTelephoneE-mail
    
    
  • Selection of Subproject

Please mark sub-project(s) you are interested in participating

Sub-projectWaterEnergyEducationMedicalAgriculture
     

We hereby confirm that we fully meet the following eligibility criteria 1) to 5)

(please check the box if you confirm that you fully meet the following criteria):☐

  1. Bidders shall be Japanese nationals (Japanese physical persons or juridical persons controlled by Japanese physical persons). 
  2. Bidders shall be Japanese companies incorporated and registered under Japan Law with their headquarters in Japan.
  3. The majority of bidders’ capital with voting rights shall be owned by Japanese nationals and majority of board members are Japanese physical persons.
  4. Bidders shall not fall under any of the items of Article 26, paragraph 1 of the Foreign Exchange and Foreign Trade Act (Gaikokukawase-oyobi-Gaikokuboeki-Ho, Law No.228 of 1949, Japan).
  5. Bidders shall not be debarred by the Government of Japan and/or by the Japan International Cooperation Agency (JICA) from participating in bidding exercises. 

We agree to submit further supporting documents to prove our eligibility (which may include copy of passports) upon request from Crown Agents (Please check the box if you agree):☐

  • Track Record

For the Subproject you wish to participate, please fill in forms as below.

Participant may insert rows if necessary.

  1. The Subproject for Urgent Improvement of Energy Service
Name of ProductQuantityClient Name with ContactContract AmountContract Date/YearSupplied CountryODA or Commercial
       
       
       
  • The Subproject for Urgent Improvement of Water Supply
Name of ProductQuantityClient Name with ContactContract AmountContract Date/YearSupplied CountryODA or Commercial
       
       
       
  • The Subproject for Urgent Improvement of Equipment for Medical and Health Services
Name of ProductQuantityClient Name with ContactContract AmountContract Date/YearSupplied CountryODA or Commercial
       
       
       
  • The Subproject for Urgent Improvement of Equipment for Education Service
Name of ProductQuantityClient Name with ContactContract AmountContract Date/YearSupplied CountryODA or Commercial
       
       
       
  • The Subproject for Agriculture Sector Urgent Support
Name of ProductQuantityClient Name with ContactContract AmountContract Date/YearSupplied CountryODA or Commercial
       
       
       
  • Have any one of subsidiaries, branch offices and agents (registered companies) in Ukraine, Poland or Romania which meet the following conditions:
  • subsidiaries and/or branch offices shall have a minimum of three (3) years of continuous business history as of 1 April 2023; and/or
  • agents (registered companies) shall have a minimum of three (3) years of continuous contract with Companies as of 1 April 2023.
  • Country Name:                                                                                                          
  • Registered Address:                                                                                                 
  • Name of Subsidiary / Branch Office / Agent:                                               
  • Person in charge: (Name)                                                                                     

(Tel)                                   (E-mail)                                        

*Evidential documents such as the registration and the agent contract shall be submitted.  English translation is also required.

  • In the case of the (3) above stated is agents (registered companies):
  • There must be accumulated transaction record of minimum JPY 5,000,000 between the bidder and the agents (registered companies) during the period from 1 January 2018 until 1 April 2023:
YearName & Quantity of ProductsContract Amount (JPY)
   
   
   
  • The agents (registered companies) shall evidence three (3) or more track record of overseas trading (import or export)1 from 1 January 2018 until 1 April 2023.  Each supply contract is valued JPY10,000,000 or more:
YearClient/Customer NameDestination (Country)Name & Quantity of ProductsContract Amount (JPY)
     
     
     

1If the agent (registered company) is located in Ukraine, they may submit evidence relating to domestic trading activities.

*Evidential documents such as contract copies and remittance records shall be submitted. English translation is also required.

*In case you cannot meet the criteria (2), (3) and (4) above, please fill out (2), (3) and (4) with the parent company’s information and (5) below with parent company’s information.

Please submit the power of attorney issued by the parent company together with this Registration Form.

  • Parent Company
  • Company Name:                                                                                                                                          
  • Contact Persons (please name the person in charge):
NameTitle / SectionTelephoneE-mail
    
  • Our parent company fully meets the eligibility criteria 1) to 5) of (1) Japanese Nationals (please check the box if you confirm that your parent company fully meets the criteria): ☐

We declare that all the above information is true and correct.  We also understand that misrepresentations or incorrect information provided in this form can result in our disqualification.

  …………………………………….. Authorised Signature  …………………………………….. Name Position/Title Company Name  …………………………………….. Date