Service Provider Qualification Form - Generic

PART A - GENERAL INFORMATION

Your Organisation Details

Company Name*

Trading name

What is your ABN*

Contact Person*

Type of Organisation*

Department

Office number

Mobile Number*

Email Address*

Office Street Address

PO Box Address*

How long has the business been established?

Provide names of other Organisations to who you provide a similar service

Organisation Name and Location 1

Organisation Name and Location 2

Provide names of Organisations who are your top competitors

Organisation Name and Location 1

Organisation Name and Location 2

Provide details of referees

Organisation No. 1: Organisation Name

Organisation No. 1: Contact Name

Organisation No. 1: Contact Number

Organisation No. 2: Organisation Name

Organisation No. 2: Contact Name

Organisation No. 2: Contact Number

PART B - WORKFORCE

State and National Providers

If you are a National Provider, please tick relevant state box/es below.

Postcode

Kilometers

Comments

Size of Workforce - Australia

Trade Staff (direct employees)*

Trade Staff (subcontractors)

PART C - INVOICING AND PAYMENT TERMS

Invoicing and Reporting

Quoject standard payment terms are 30 days from end of month. Please confirm your acceptance of these terms*

Agree

Disagree

To be discussed

Account Department Details

Accounts Contact

Accounts Contact Telephone Number

Accounts Contact Email Address

Payment - Bank Details

Name of your Bank*

Account Name*

BSB*

Account Number*

Email address for remittance advices*

PART D - POLICIES AND PROCEDURES

Does your Organisation have an Occupational Health and Safety Management System accredited to AS/NZ 4801?

If yes, please attach your Certificate of Registration

(Maximum size: 1,000 KB )

If no to the above, please answer the following:

Does your Organisation have a Health and Safety at work policy?

Does your Organisation have a documented Risk Assessment in place?

Does your Organisation have Safe Work Statements in place?

Does your business have an Incident Notification and Management Process in place?

Does your business conduct a pre start Job Safety Analysis (JSA)?

Describe how does your organisation monitors and audit the work performed by your subcontractors?

Does your Organisation have an Environmental Management System accredited to ISO 14001? If yes, please attach your Certificate of Registration

(Maximum size: 1,000 KB )

If your Organisation's Quality Management System accredited to ISO 9001? If yes, please attach a copy of your Certificate of Registration

(Maximum size: 1,000 KB )

PART E - ACCREDITATION

Other Accreditation

Confirm all trade staff (including subcontractors) have an OHS General Industry Induction Card (e.g. white card/blue card)*

Confirm all staff (including subcontractors) working on site have a National Criminal History Check (NCHC - AUS)

Are you CM3 Accredited?

Yes

If yes, please upload certificate

(Maximum size: 1,000 KB )

PART F - LICENCES AND INSURANCES DETAILS

Licences - Mandatory

Trade Licence Number*

Expiry*

Trade Licence - Please attach*

(Maximum size: 1,000 KB )

Contractor Licence Number*

Expiry*

Contractor Licence - Please attach*

(Maximum size: 1,000 KB )

Any other Licences?

Please attach copy(ies)

(Maximum size: 1,000 KB )

Insurances

If a Sole Trader, confirm you have income protection insurance by attaching your certificate

(Maximum size: 1,000 KB )

Confirm your Organisation has workers compensation insurance by attaching your certificate

(Maximum size: 1,000 KB )

Confirm your Organisation has minimum public liability insurance of $10 million by attaching your certificate*

(Maximum size: 1,000 KB )

If your Organisation has professional indemnity insurance min $10 million please attach your certificate

(Maximum size: 1,000 KB )

Does your Organisation have product liability insurance min of $10 million?

Yes

If yes

(Maximum size: 1,000 KB )

Does your Organisation have asbestos removal insurance?

Yes

If yes

(Maximum size: 1,000 KB )

PART G - SCHEDULE OF RATES

PLEASE NOTE THESE RATES ARE TO BE INDICATIVE ONLY

Normal Hours - Call Out Charge (includes time and travel to site) $ Fee

Normal Hours - Hourly Rate $/hr

After Hours - Call Out Charge (includes time and travel to site) $ Fee

After Hours - Charge (includes call out charge, minimum 4 hours on site, travel to site) $ Fee

After Hours - Hourly Rate (after the initial 4 hours) $/hr

Parts Margin %

Value adds

Please state what discounts, rebates or volume incentives your organisation can offer?

Additional comments, if required

Authorised Person Name*

Signature*