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[COMPANYS LETTER HEAD]

L LE ET TT TE ER R T TO O A AC CC CO OM MP PA AN NY Y F FO OR RM MS S

Dear Sir,

We would like to thank you for expressi ng interest in providing services to the Regional
Roads Development Project (RRDP).


A Joint Venture (JV) /Joint Operation (JO) to be considered eligible, the Expression of Interest
must include a Letter of Intent from the lead firm and each partner, indicating their intent to
form a Joint Venture, nominating the lead firm, and confirming that all partners agree to be held
jointly and severally liable if awarded the contract.

For the preparation of the shortlist an important criteria to be considered will be that under a Joint
Venture/JO each partner has to be reasonably qualified to take over the responsibilities and role of
any of the partners in case one of them fails to perform or withdraws.

The Expression of Interest must include properly completed forms and profiles for each
participating member.



Yours sincerely,





















Note: Form 02A and Form 03 to Form 04b must be filled in Microsoft Excel format.










DECLARATION
FORM 01A
FORM 01B
FORM 02A
FORM 02B
FORM 03
FORM 04a
FORM 04b
DECLARATION

Date: __________________


We, the undersigned, express our interest for the contract packages of TECHNICAL ASSISTANCE
FOR:
()

ROAD SAFETY SUPPORT
HIV/AIDS AND ANTI-TRAFFICKING PREVENTION PROGRAM

and declare that:

(a) all documents submitted by us for the purpose of evaluation for consultant short-listing for the
above contract package are true and correct, and in the event the documents are proved to
be incorrect, we agree to bear all consequences, such as deleted from the shot-list, subject to
the appropriate procedures in accordance with the Indonesian laws, ADB Guidelines on the
use of Consultants, and IDB Guidelines for the use of Consultants;

(b) we have not been declared ineligible by the Bank or the Government of Republic of Indonesia;

(c) we have not been engaged to prepare such TOR as a firm, subconsultancy, or joint venture;
and

(d) no full-time or part-time or contracted expert employed by our firm, subconsultancy, or joint
venture has been engaged to prepare such TOR.

(e) we understand that you may cancel the selection process at any time and that you are neither
bound to accept any application that you may receive nor to invite the short-listed consultants
to submit proposals for the above contract packages, without incurring any liability to the
Applicants.
We have written this declaration conscientiously.

Signed ____________________________
Name ____________________________ In the Capacity of _______________________

Duly authorized to sign the application for and on behalf of:
Name of Company _______________________________________________________________
Address ______________________________________________________________________
______________________________________________________________________
Dated on _________ day of _________ , 2011








FORM 01A
COMPANY INFORMATION *


Contract Title (*) : ROAD SAFETY SUPPORT
HIV/AIDS AND ANTI-TRAFFICKING PREVENTION PROGRAM


1 Name of Company
2 Head Office Address
Telephone
Fax
E-mail

3 Indonesian Branch Office Address
Telephone
Fax
E-mail

4 Name of Director

5 Tax Registration Number (NPWP)

6 Professional Society Membership 1.
2.
7 Certificate (LPJK/BUJKK) 1.
2.
8 Registered in the Ministry of Public
Works

9 Name of Bank Reference 1.
2.

INSTRUCTIONS :
1. Three (3) copies shall be submitted to the Committees.
2. Row 4 : Please specify whether head office or branch office
3. Row 7 : Especially for domestic companies. Fill in with No., Date, and Validity of the certicates.
Please provide their copies.
4. Row 8 : For foreign companies only. Fill in with No., date, (if any)







FORM 01B


MANAGEMENT and ORGANIZATION INFORMATION *


1 Provide an organisation chart showing the responsibilities for this contract within the
overall Company organisation
2
Describe how your Company provides for Quality Assurance of its activities (eg, ISO
9001 Registered)
3
In order to indicate the scale of the Companys operations, provide:
A statement of total annual turnover for the last 5 years.
4 What year was the Company first established?

5
International Companies:
i. How long has the Company been operating in Indonesia?
ii. In which other countries in Asia/SE Asia does the Company operate?

Note: (*) All information provided will be subject to Audit in the event that the Joint Venture is
determined to be the winning bidder for the Services. Contract award will be subject to
a satisfactory audit result.

[COMPANYS LETTER HEAD]


FORM 02A
SUMMARY OF FIRMS EXPERIENCE
(EXPERIENCES OF THE COMPANY WITHIN THE LAST FIVE YEARS)

No.
Country and
location within
the Country
Name of Employer/
Client
Contract of works/services/assignments Period of contract
Value of
Contract
Companys
sharing value
No.
Date
Title of works/
services/assignments
Brief description of
works/services/
assignments
Start date
Completion
date
[mm-dd-yy] [mm-dd-yy] [mm-dd-yy] [Equiv. US$] [Equiv. US$]
1 2 3 4 5 6 7 8 9 10 11














NOTES :
1. All columns are required to be completed; otherwise the corresponding row will not be evaluated.
2. Column 2 : the location where the contract was mainly carried out
3. Column 7 : especially the main scope and objectives of the contract
4. Column 10 and 11 : convert the contract value in other currencies to US$; use the exchange rate that was in effect on the month the contract was signed (this will be
provided by the Committee)
5. Column 11 : the Companys sharing value for contract carried out by an association, or the same value with Column 10 if carried out only by a single firm
6. Please fill the table in Microsoft Excel format

[COMPANYS LETTER HEAD]




FORM 02B


Firms Experience


[Using the format below, provide information on Consulting Services assignments under-
taken by your Company within the last 5 years either individually as a corporate entity or
as a Joint Venture partner. Note that a maximum of 15 such assignments is to be submit-
ted.]
Firms Name:

Assignment name:


Value of the contract (equivalent US$)


Country:
Location within country:

Duration of assignment (months):
Start date/completion date (mm/yy):

Name and Address of Client:


Professional staff-months of the assign-
ment:
Total number provided by your company:

Contract No.


Company share of contract value
(equivalent US$):

Name of associated Consultants, if any:


Name of senior professional staff of your
firm involved and functions performed (in-
dicate most significant such as Project Di-
rector/Coordinator, Team Leader):






Narrative description of Project:




Description of actual services provided by your staff within the assignment:









[COMPANYS LETTER HEAD]


FORM 03
PERSONNEL
(PERMANENT OR TEMPORARY STAFF EMPLOYED BY THE COMPANY WITHIN THE LAST TEN YEARS)

No. Name of Staff
Proposed
Position
Nationality
Date of
Birth
Educational Background Length of
period with
the Company
Country of current
domicile Name of University/
College
Degree of
Education
Field/Discipline
Year of
Graduation
[dd-mm-yy] [yy] [mm]
1 2 3 4 5 6 7 8 9 10a 10b 11















NOTES :
1. All columns are required to be completed; otherwise the corresponding row will not be evaluated.
2. Column 2 : List only those worked with the Company within the last ten years (2001 2011)
3. Column 6 : D3 for diploma; S1 for undergraduated; S2 for Master postgraduated; S3 for Ph.D.
4. Column 9a and 9b : Total length of the periods the Staff joined the Company (not only within the last ten years).
5. Please fill the table in Microsoft Excel format

FORM 04a
CURRENT WORK LOADS


No.
Title of
works/services/assignments
Name of
Employer/Client
On-going Contract Current progress Current
remaining
Contract Value
Contract No.
Contract
Date
Contract Value
Companys
sharing value
Completion
date %
Value
[dd-mm-yy] [equiv. US$] [equiv. US$] [dd-mm-yy] [equiv. US$] [equiv. US$]
1 2 3 4 5 6 7 8 9 10 11 = [7 10]



















T O T A L


Please fill the table in Microsoft Excel format without alteration to the format


[COMPANYS LETTER HEAD]


FORM 04b
SUMMARY OF THE LATEST BALANCE SHEET


No. Description
Value
[Rupiah] [Equiv. US$]
1 2 3 4
1 Current Assets
2 Fixed Assets
3 Other Assets
Total of Assets [AC]
4 Short Term Loan
5 Long Term Loan
Total of Loan [PS]
Net Worth [NW] = [AC] [PS]

NOTES :
1. This is only a sample format. Please provide the evidence for the latest balance sheet.
2. Column 3 : To be filled only by Companies whose balance sheet is in Rupiah.
3. Please fill the table in Microsoft Excel format
















ATTACHMENT TO APPLICATION FORMS - RRDP
AREAS OF EXPERTISE
REQUIRED FOR THE CONTRACT PACKAGES

ROAD SAFETY SUPPORT
HIV/AIDS AND ANTI-TRAFFICKING
PREVENTION PROGRAM
Team Leader
Road Safety Engineer (International)
Highway Engineer
Road Safety Engineer (National)
Training Expert
Team Leader (Social Expert)
Law Expert
Public Health Expert
Training Expert
Curriculum Expert
Graphic Design Expert

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