ANNEX C
Open call for tender F/SE/11/02

Medical services for Staff Members of the European Union Agency for Fundamental Rights (FRA)
STANDARD SUBMISSION FORM	
SUBMITTED BY:
Name: ……………………………………………
Contact person: ……………………………………
Address: ……………………………………………
Phone: ……………………………………………
Fax: ……………………………………………
Email: ……………………………………………
1. PREAMBLE
Tenderers are requested to include in their tenders all the information and documents requested in the forms attached, in accordance with Annex A – Tender Specifications and the instructions below:
•	All forms must be dated, signed and stamped by a person authorised to sign on behalf of the tenderer. 
•	In case of a consortium or group of companies, the tender must be signed by the person appointed in the power of attorney (Form A.4) as authorised to sign the tender on behalf of the consortium or group of companies. 
•	Each consortium partner must sign a Declaration of Honour with respect to the Exclusion Criteria and Absence of Conflict of Interest (Form B.1). When subcontracting exceeds or equals 20% of the total contract value, each subcontractor must also sign the Declaration of Honour.
•	Each proposed subcontractor must complete and sign the Letter of Intent included in Form A.6. 
•	If the tenderer relies on the economic, financial, technical and professional capacity of the proposed subcontractor(s) to meet the selection criteria, then the subcontractors shall also complete the forms included under Section C. In any other case, the forms included under Section C shall only be completed by the tenderer or by the partners in case of consortium or group of companies. 
•	Tenderers’ financial offer shall be prepared in accordance with Form F.1 (for Lot 1) and Form F.2 and F.3 (for Lot 2) and shall be submitted in a separate sealed envelope clearly stating “Financial Offer”.
2.	CHOICE OF LOT(S) 
Please indicate for which lot(s) you are submitting a tender.
Lot No	Title	Choice(s)	

Please tick with an X where appropriate

SECTION A – TENDERERS IDENTIFICATION

FORM A.1 – ADMINISTRATIVE DETAILS	
1. TENDERER’S DETAILS	
Company or organisations’ name		
Legal form 		
Date of registration		
Country of registration		
Registration number		
VAT number		
Address of registered office 		
Contact address (if different)		
URL		
2. TENDERERS’ REPRESENTATIVE(S) 	
Person authorised to sign the contract on behalf of the tenderer:	
Name		
Forename		
Position 		
Telephone 		
Fax 		
Email 		
Contact person regarding this tender:	
Name		
Forename		
Position 		
Telephone 		
Fax 		
Email 		

Signed (authorised signature) on behalf of the Tenderer

Full name:……………………………………..
Date:……………………………………………
Signature:……………………………………...	Stamp:………

FORM A.2 – LEGAL ENTITIES FORM

A standard template in each EU language is available at:
http://ec.europa.eu/budget/execution/legal_entities_en.htm 
Please choose the appropriate form (legal entity form for either individuals, private companies or public entities) and attach the necessary supporting documents as required (see instructions in the file). 

FORM A.3 – BANK IDENTIFICATION FORM
A standard template in each EU language is available at:
http://ec.europa.eu/budget/execution/ftiers_en.htm

FORM A.4 – POWER OF ATTORNEY
(DESIGNATING ONE OF THE COMPANIES OF THE GROUP AS LEADER AND GIVING A MANDATE TO IT)
We, the undersigned:
– Signatory 1 (Name, Function, Company, Registered address, VAT Number)
– Signatory 2 (Name, Function, Company, Registered address, VAT Number)
– …..
– Signatory N (Name, Function, Company, Registered address, VAT Number),
Each of them having the legal capacity required to act on behalf of his/her company,
HEREBY AGREE AS FOLLOWS:
1.	In case the European Union Agency for Fundamental Rights awards the Contract F/SE/11/02 ( the Contract ) to Company 1, Company 2, …, Company N ( the Group Members), based on the joint offer submitted by them on [complete] for the provision of Medical Services for Staff Members of the FRA  (the Services ), all the partners, as co-signatories of the Contract:
a.	Shall be jointly and severally liable towards the European Union Agency for Fundamental Rights for the performance of the Contract.
b.	Shall comply with the terms and conditions of the Contract and ensure the proper execution of their respective share of the Supplies and/or the Services.
2.	To this effect, the Group Members designate Company X as Group Leader. [N.B.: The Group Leader has to be one of the Group Members]
3.	Payments by the European Union Agency for Fundamental Rights related to the Supplies or the Services shall be made through the Group Leader’s bank account .[Provide details on bank, address, account number, etc.].
4.	The Group Members grant to the Group Leader all the necessary powers to act on their behalf in connection with the Supplies and/or the Services. This mandate involves in particular the following tasks :
a.	The Group Leader shall sign any contractual documents — including the Contract — and issue any invoices related to the Supplies or the Services on behalf of the Group Members.
b.	The Group Leader shall act as single point of contact for the European Union Agency for Fundamental Rights in connection with the Supplies and/or the Services to be provided under the Contract. It shall co-ordinate the provision of the Supplies and/or the Services by the Group Members to the European Union Agency for Fundamental Rights, and shall see to a proper administration of the Contract.
Any modification to the present agreement / power of attorney shall be subject to approval from the European Union Agency for Fundamental Rights.
This agreement / power of attorney shall expire when all the contractual obligations of the Group Members towards the European Union Agency for Fundamental Rights in connection with the Supplies and/or the Services to be provided under the Contract have ceased to exist. The parties cannot terminate it before that date without the consent of the European Union Agency for Fundamental Rights.

Signed in …………………… on ……….. ………
Name
Function
Company

FORM A.5 – STATEMENT ON SUBCONTRACTING

Please indicate (by ticking the appropriate box) whether the tenderer intends to subcontract all or part of the performance of the Contract, if awarded. 
□	YES, the tenderer intends to subcontract all or part of the performance of the Contract, if awarded.
□	NO, the tenderer does not intend to subcontract all or part of the performance of the Contract, if awarded.
If YES, please specify which parts of the Contract, and the name and address of any subcontractor(s).
Description	Percentage of the contract	Subcontractor	
	%	Name:
Address:	
	%	Name:
Address:	
	%	Name:
Address:	
	%	Name:
Address:	

 Signed (authorised signature) on behalf of the Tenderer

Full name:……………………………………..
Date:……………………………………………
Signature:……………………………………...	Stamp:………

FORM A.6 – LETTER OF INTENT FOR SUBCONTRACTORS

The undersigned: 
[complete]
Name of the company/organisation: 
[complete]
Address: 
[complete]
Tender reference:
F/SE/11/02
Declares hereby that, in case the contract is awarded to [name of the tenderer], the company/organisation that he/she represents, intends to collaborate in the execution of the tasks subject to this call for tender, in accordance with the technical specifications and the tender to which the present form is annexed, and is available to carry out its part of the tasks during the period foreseen for the execution of the contract.  
Declares hereby accepting the General Conditions of the Draft Contract attached to the invitation to tender for the above call for tenders, and in particular, those provisions referring to subcontracting and check and audits.

Place and date:

Name and signature:

SECTION B – EXCLUSION CRITERIA
FORM B.1 - DECLARATION OF HONOUR WITH RESPECT TO THE EXCLUSION CRITERIA AND ABSENCE OF CONFLICT OF INTEREST
The undersigned [name of the signatory of this form, to be completed]:
•	in his/her own name (if the economic operator is a natural person)
or
•	representing (if the economic operator is a legal person and the declaration is signed by a director or person with powers of representation)
official name in full:
official legal form:
official address in full:
VAT registration number:

declares that he/she / the company or organisation that he/she represents:
a)	is not bankrupt or being wound up, is not having its affairs administered by the courts, has not entered into an arrangement with creditors, has not suspended business activities, is not the subject of proceedings concerning those matters, and is not in any analogous situation arising from a similar procedure provided for in national legislation or regulations;
b)	has not been convicted of an offence concerning professional conduct by a judgment which has the force of res judicata;
c)	has not been guilty of grave professional misconduct proven by any means which the contracting authorities can justify; 
d)	has fulfilled all its obligations relating to the payment of social security contributions and the payment of taxes in accordance with the legal provisions of the country in which it is established, with those of the country of the contracting authority and those of the country where the contract is to be carried out; 
e)	has not been the subject of a judgement which has the force of res judicata for fraud, corruption, involvement in a criminal organisation or any other illegal activity detrimental to the Union’s financial interests;
f)	is not a subject of the administrative penalty for being guilty of misrepresentation in supplying the information required by the contracting authority as a condition of participation in the procurement procedure or failing to supply an information, or being declared to be in serious breach of his obligation under contract covered by the budget.
In addition, the undersigned declares on their honour:
g)	they have no conflict of interest in connection with the contract; a conflict of interest could arise in particular as a result of economic interests, political or national affinities, family or emotional ties or any other relevant connection or shared interest;

h)	they will inform the contracting authority, without delay, of any situation considered a conflict of interest or which could give rise to a conflict of interest;
i)	they have not made and will not make any offer of any type whatsoever from which an advantage can be derived under the contract;
j)	they have not granted and will not grant, have not sought and will not seek, have not attempted and will not attempt to obtain, and have not accepted and will not accept any advantage, financial or in kind, to or from any party whatsoever, constituting an illegal practice or involving corruption, either directly or indirectly, as an incentive or reward relating to award of the contract.
k) that the information provided to the Commission within the context of this invitation to tender is accurate, sincere and complete.
l) that in case of award of contract, they shall provide the evidence that they are not in any of the situations described in points a, b, d, e above.
For situations described in (a), (b) and (e), production of a recent extract from the judicial record is required or, failing that, a recent equivalent document issued by a judicial or administrative authority in the country of origin or provenance showing that those requirements are satisfied. Where the tenderer is a legal person and the national legislation of the country in which the tenderer is established does not allow the provision of such documents for legal persons, the documents should be provided for natural persons, such as the company directors or any person with powers of representation, decision making or control in relation to the tenderer. 
For the situation described in point (d) above, recent certificates or letters issued by the competent authorities of the State concerned are required. These documents must provide evidence covering all taxes and social security contributions for which the tenderer is liable, including for example, VAT, income tax (natural persons only), company tax (legal persons only) and social security contributions.
For any of the situations (a), (b), (d) or (e), where any document described in two paragraphs above is not issued in the country concerned, it may be replaced by a sworn or, failing that, a solemn statement made by the interested party before a judicial or administrative authority, a notary or a qualified professional body in his country of origin or provenance.
By signing this form, the undersigned acknowledges that they have been acquainted with the administrative and financial penalties described under art 133 and 134 b of the Implementing Rules (Commission Regulation 2342/2002 of 23/12/02), which may be applied if any of the declarations or information provided prove to be false.

Full name:……………………………..  Date:………………………… 

Signature:………………………..	Stamp:…………………………

SECTION C – SELECTION CRITERIA 
FORM C.1 –EVIDENCE OF PROFESSIONAL RISK INDEMNITY INSURANCE
Please attach evidence of professional risk indemnity insurance as indicated in Section 17.2.1 (a), Annex A- Tender Specifications

FORM C.2 – COPY OF BALANCE SHEETS  (only for Lot 2)
Please attached copy of balance sheets and profit and loss accounts in accordance with the instructions provided in Section 17.2.1 (b), Annex A – Tender Specifications.

FORM C.3 – STATEMENT OF ANNUAL AVERAGE TURNOVER (only for Lot 2)
Please fill in the table below in accordance with the instructions provided in Section 17.2.1 c), Annex A – Tender Specifications:
Statement on annual overall turnover (in EURO)	
Tenderer’s name	Current year -2	Current year -1	
Partner 1			
Partner 2			
Etc…			
Total			
(please add rows and columns if needed).

Signed (authorised signature) on behalf of the Tenderer

Full name:……………………………………..
Date:……………………………………………
Signature:……………………………………...	Stamp:………
FROM C.4: PROOF OF TECHNICAL AND PROFESSIONAL CAPACITY 
FOR LOT 1
Please provide the following information/documents:
a)	Two CVs in Europass for the profile of Medical Advisor. The CV template and the respective instructions can be downloaded under the following link: 
http://europass.cedefop.europa.eu/europass/home/hornav/Downloads.csp
b)	Copy of the degree in Medicine obtained in a medical university/school in one of the EU member states or equivalent qualification. 
c)	Copy of the certificate of registration as general practitioner or medical specialist authorizing the practice of medicine in Austrian territory. 
b)	
FROM C.5:  PROOF OF TECHNICAL AND PROFESSIONAL CAPACITY
 FOR LOT 2
Please provide the following information/documents:
a)	Proof that the contractor is authorised to perform the medical services required in the tender under the Austrian law, as evidenced by inclusion in the relevant official professional register.
b)	A list with a detailed description of similar services provided to private or public clients, proving that the tenderer is capable to cover all services required under this tender.
c)	A description of the internal structure of the Medical Centre, its organisational division, medical areas covered by the centre, information on the medical and administrative staff, and a description of the equipment in use for the performance of all requested examinations. The organisational chart of the Medical Centre shall be included.

FINANCIAL OFFER FORMS
FORM F.1 – FINANCIAL OFFER (LOT 1) 
[To be submitted in a separate sealed envelope clearly stating “Financial Offer” following the instructions laid down in Annex A – Tender Specifications]
Provision of Medical services for Staff Members of the European Union Agency for Fundamental Rights (FRA) 
F/SE/11/02
IDENTIFICATION OF THE TENDERER:
Name: ……………………………………………
Contact person: ……………………………………
Address: ……………………………………………
Phone: ……………………………………………
Fax: ……………………………………………
Email: ……………………………………………
Item	Concept	Price in EUR	
1	Hourly rate		
2	Daily fee first day of mission(*)		
3	Daily fee from the second day of mission on (**)		
(*) The daily fee shall include travel costs, accommodation and meals
(**) The daily fee shall include only the cost for accommodation and meals  

Signed (authorised signature) on behalf of the Tenderer

Full name:……………………………………..
Date:……………………………………………
Signature:……………………………………...	Stamp:………
FORM F.2 – FINANCIAL OFFER (LOT 2) 
[To be submitted in a separate sealed envelope clearly stating “Financial Offer” following the instructions laid down in Annex A – Tender Specifications]
Provision of Medical services for Staff Members of the European Union Agency for Fundamental Rights (FRA) 
F/SE/11/02
IDENTIFICATION OF THE TENDERER:
Name: ……………………………………………
Contact person: ……………………………………
Address: ……………………………………………
Phone: ……………………………………………
Fax: ……………………………………………
Email: ……………………………………………

Item	Concept	Price in EUR (per medical examination per person)	
1	Annual medical examination of staff, including medical visit, laboratory and other exams.		
2	Pre-employment medical examination of candidates, including medical visit, laboratory tests and other exams.  		
Note: You are requested to complete the attached excel sheet containing Form F.3 (Annex 1 to the Financial Offer for Lot 2) for an itemised breakdown of prices. Please initialise every page and sign last page.

Signed (authorised signature) on behalf of the Tenderer:

Full name:……………………………………..
Date:……………………………………………
Signature:……………………………………...	Stamp:………