Supplier Registration Form

1. Company Name *

2. Physical Address *

3. Postal Address *

4. Telephone Number *

5. E-mail Address *

6. Name and Title of Company Representative(s) *

7. Direct E-mail address of Company Representative *

8. Direct Number of Company Representative *

(a) Telephone

(b) Mobile

9. Date Company was established *

10. Gross annual sales for the last 12 months (ZMW) *

11. Legal Structure *

(a) Corporation

(b) Partnership

(c) Sole Proprietorship

(d) Joint Venture

(e) Franchise

12. Type of business *

(a) Retailer

(b) Distributor/Dealer

(c) Wholesaler

(d) Manufacturer

(e) Service Provider

(f) Other

13. Details on services or goods your company supplies *

14. State Lot(s) bided for (Select all that apply)

(a) Lot 1

(b) Lot 2

(c) Lot 3

(d) Lot 4

15. Business Geographic Location *

(a) Local (Lusaka based)

(b) National (From other towns)

(c) Regional

16. Have you conducted business with EIZ before? *

(a) Yes

(b) No

1. Bank Name *

2. Bank Address *

3. Beneficiary name *

4. Bank Account Number *

5. SWIFT code *

6. Account Currency *

(a) Certificate of incorporation/registration with PACRA * (PDF, Max 5MB)

(b) Valid Tax clearance certificate from ZRA * (PDF, Max 5MB)

(c) Proof of certification with other relevant bodies (PDF, Max 5MB)

(d) Any other information relevant to this Supplier Registration (PDF, Max 5MB)

Name *

Title/Position *

Signature (Full Name) *

Date *

By submitting this form, I/We declare that the information contained in this form is correct to the best of my knowledge and belief and do hereby express our interest in this procurement. *

Name and Title *

Date *

Signature (Full Name) *

The Engineering Institution of Zambia

Newsletter

Official info:

Supplier Registration Form

The Engineering Institution of Zambia

Newsletter

Official info:

EIZ News Letter