OFFER FORM ACTED INDONESIA/ FORMULIR PENAWARAN ACTED INDONESIA

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1 OFFER FORM ACTED INDONESIA/ FORMULIR PENAWARAN ACTED INDONESIA Date/Tanggal: Tender N / Tender: T/09BNC/34I/HWF-GWF/JAKARTA/ /3 To be Filled by Bidder (COMPULSORY) / Untuk Diisi oleh Penawar (WAJIB) Details of Bidding Company/ Data Lengkap Perusahaan Penawar: Company Name/ Nama Perusahaan: ( ) 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: / No HP: ) b. Address/ Alamat ( ) 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

2 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 Unit Price/ Kemasan M Ukuran Unit / Jumlah Spesifikasi Item &taraf produk 1 Group Ceramic Individual Water filter 91 Water Filter with boxes water container (min 15 liters per hour) 2

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 Spesifikasi Item & taraf produk Kemasan M Ukuran Unit / Jumlah 1 Individual Ceramic Water filter 2310 Water Filter with water container (min 3 liters per hour) Unit Price / 3

4 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 Spesifikasi Item & taraf produk Kemasan M Ukuran Unit / Jumlah 1 One hour technical Training session 71 training session on water filter usage and maintenance to communities. Unit Price / Estimated delivery cost / Estimasi Biaya Pengiriman: Batches / No Batches Address of Warehouse of Destination / Alamat Gudang Tujuan Guaranteed delivery time / Waktu Pengiriman yang Dijamin Total Transportation cost / Total Biaya Transportasi () DELIVERY CONDITIONS GUARANTEED BY THE BIDDER / SYARAT PENGIRIMAN YANG DIJAMIN OLEH PENAWAR:... Days for 50% of the items/ hari untuk 50% items/barang 4

5 ... Days for 100% of the items/hari untuk 100% items/barang BIDDER S TERMS AND CONDITIONS / SYARAT DAN KETENTUAN PENAWAR: Valid of the offer/penawaran berlaku: (recommended: 2 months or more/ direkomendasikan: 2 bulan atau lebih) 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 5