Form PRO-06 Version 1.3
OFFER FORM ACTED INDONESIA/ FORMULIR PENAWARAN ACTED INDONESIA Date/Tanggal:
Tender N°/ No. Tender: T/09BNC/34I/HWF-GWF/JAKARTA/28-08-2013/3 To be Filled by Bidder (COMPULSORY) / Untuk Diisi oleh Penawar (WAJIB)
Details of Bidding Company/ Data Lengkap Perusahaan Penawar: 1. Company Name/ Nama Perusahaan:
(
)
2. Company Authorized Representative Name/:
(
)
(
)
Nama Resmi Perwakilan Perusahaan 3. Company Registration No/ No Registrasi Perusahaan:
No/Country (Negara)/ Ministry (Kementrian)
4. Company Specialization/ Spesialisasi Perusahaan:
(
)
5. Mailing Address/ Alamat Surat-Menyurat:
(
)
Country(Negara )/Governorate (Kegubernuran) /City (Kota )/St name (Nama Jalan)/Shop-Office No (No Kantor Toko)
a.
Contact Number/ No Kontak:
(Telp:
b.
E-mail Address/ Alamat E-mail:
(
/ No HP:
)
)
I undersigned ___________________________, agree to provide ACTED, non-profit NGO, with items answering the following specifications, according to the general conditions and responsibilities that I engage myself to follow. 1
Form PRO-06 Version 1.3 Dengan ini saya___________________________, setuju untuk menyediakan ACTED, Lembaga Ornop non-profit, dengan item/barang dengan spesifikasi sebagai berikut, sesuai dengan persyaratan umum dan tanggungjawab bahwa saya patuhi sebagai berikut.
PLEASE FILL IN THE FOLLOWING TABLES, ONE FOR EACH BATCH, EACH BATCH CORRESPONDING TO PROCUREMENT OF WATER FILTERS SILAHKAN ISI TABEL-TABEL BERIKUT, SATU UNTUK MASING-MASING BATCH,SETIAP BATCH BERHUBUNGAN DENGAN PROCUREMENT OF WATER FILTERS: BATCH 1: Groups Ceramic Water Filter
Delivery conditions: ACTED Betun (all costs and duties paid by supplier), ACTED office at Jl. Jurusan Umakatahan, Kota Betun, Belu, Nusa Tenggara Timur, Indonesia Delivery deadline: By 31st October 2013 No.
Item Specifications &
Supplier’s Specification
Brand
Country of
Packaging /
INCOTER
Measuring Unit /
Quantity
Unit Price/
Total Price /
product stage /
(if different) /
Name /
Origin
Kemasan
M
Ukuran Unit
/ Jumlah
Harga Unit
Harga Total
Spesifikasi Item
Spesifikasi Pemasok
Merk
(made in)I /
IDR
IDR
&taraf produk
(jika berbeda)
Asal Negara (dibuat di)I
1
Group Water
Ceramic Filter
with
Individual
Water filter
91
boxes
water container (min 15 liters per hour) Grand - Total
IDR
BIDDER’S COMMENTS (KOMENTAR) /REMARKS (CATATAN PENAWAR): 1. 2.
2
Form PRO-06 Version 1.3
BATCH 2: Individual Ceramic Water filters
Delivery conditions: Across 33 villages listed Across 33 communities in Belu district, NTT (listed in Annex A) (all costs and duties paid by supplier) Delivery deadline: By 31st October 2013 No.
Item Specifications &
Supplier’s Specification
Brand
Country of
Packaging /
INCOTER
Measuring Unit /
Quantity
Unit Price /
Total Price /
product stage /
(if different) /
Name /
Origin
Kemasan
M
Ukuran Unit
/ Jumlah
Harga Unit
Harga Total
Spesifikasi Item &
Spesifikasi Pemasok
Merk
(made in)I /
IDR
IDR
taraf produk
(jika berbeda)
Asal Negara (dibuat di)I
1
Individual
Ceramic
Water filter
2310
Water Filter with water container (min 3 liters per hour) Grand - Total
IDR
BIDDER’S COMMENTS (KOMENTAR) /REMARKS (CATATAN PENAWAR): 1. 2.
3
Form PRO-06 Version 1.3 BATCH 3: Technical training session on water filter usage
Delivery conditions: Across 33 villages listed Across 33 communities in Belu district, NTT (listed in Annex A) (all costs and duties paid by supplier) Delivery deadline: By 30th November 2013 No.
Item Specifications &
Supplier’s Specification
Brand
Country of
Packaging /
INCOTER
Measuring Unit /
Quantity
Unit Price /
Total Price /
product stage /
(if different) /
Name /
Origin
Kemasan
M
Ukuran Unit
/ Jumlah
Harga Unit
Harga Total
Spesifikasi Item &
Spesifikasi Pemasok
Merk
(made in)I /
IDR
IDR
taraf produk
(jika berbeda)
Asal Negara (dibuat di)I
1
Training session
One hour technical
71
training session on water
filter
usage
and maintenance to communities. Grand - Total
IDR
BIDDER’S COMMENTS (KOMENTAR) /REMARKS (CATATAN PENAWAR): 1. 2.
Estimated delivery cost / Estimasi Biaya Pengiriman:
Batches No. /
Address of Warehouse of Destination /
No Batches
Alamat Gudang Tujuan
Guaranteed delivery time /
Total Transportation cost /
Waktu Pengiriman yang
Total Biaya Transportasi
Dijamin
(IDR)
DELIVERY CONDITIONS GUARANTEED BY THE BIDDER / SYARAT PENGIRIMAN YANG DIJAMIN OLEH PENAWAR: ................................................. Days for 50% of the items/ hari untuk 50% items/barang 4
Form PRO-06 Version 1.3 ................................................. Days for 100% of the items/hari untuk 100% items/barang
BIDDER’S TERMS AND CONDITIONS / SYARAT DAN KETENTUAN PENAWAR: 1. Valid of the offer/Penawaran berlaku:
_______________________ (recommended: 2 months or more/ direkomendasikan: 2 bulan atau lebih)
2. Terms of delivery/Ketentuan pengiriman: _______________________ 3. Terms of payment/Ketentuan pembayaran:
_______________________
Name of Bidder’s Authorized Representative/ Nama Perwakilan Resmi Penawar: ________________________ Authorized signature and stamp/Tanda tangan dan Stempel resmi: ________________________ Date/ Tanggal: ________________________
NB: in case of Request for Tender, please attach the service proposal to the present offer form / untuk permintaan Tender, silahkan cantumkan tawaran pelayanan pada formulir penawaran ini
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