Q-HSE AFRICA DEPARTMENT

SUPPLIER INFORMATION FORM

Document N°: QUA-F-0013 Rev 01

1. GENERAL DESCRIPTION OF YOUR COMPANY

1- Company Name:...........................................................................................................................................
2- Activities:......................................................................................................................................................
3- Type of service provided:.............................................................................................................................
4- Specific Nature:
None: Monopoly in law: De facto monopoly:
5- Address:.......................................................................................................................................................
..........................................................................................................................................................................
Tel: Fax: e-mail: .............................................................

Last Names and First Names Tel e-mail

Management

Sales Manager

Operations Manager

2. FINANCIAL INFORMATION

1- Bank Details:................................................................................................................................................
..........................................................................................................................................................................
2- Capital:.........................................................................................................................................................
..........................................................................................................................................................................
Business volume for the past two years % with the Bolloré Group

3. ADMINISTRATIVE INFORMATION
Yes No
Taxpayer card
Occupational Tax
Social Insurance registration
Tax certificate
Certificate of Bank domiciliation
VAT System

4. Q-HSE INFORMATION
4.1. Organisation
Department Staff Number Subcontracted staff
Operations
Quality
Hygiene, Safety and Environment
4.2. Regulatory situation
In possession of all clearance or authorizations requested for the activities?
 Q-HSE AFRICA DEPARTMENT
SUPPLIER INFORMATION FORM
Document N°: QUA-F-0013 Rev 01

(Provide list of the regulations and law applicable)

N/A Yes No
Compliance with all laws and regulations requirements applicable to your activities?
(Provide list of the regulations and law applicable)
N/A Yes No
4.3. Quality Management System
Quality Management System (QMS) implemented? (Provide copy of the quality manual and relevant procedures list)
N/A Yes No
QMS certified (ISO 9001 standard) by an accredited certifying body? (Provide copy of the certificate)
N/A Yes No

4.4. HSE Management System

HSE Management System implemented? (Provide copy of HSE manual and relevant procedures list)
N/A Yes No
HSE Management System certified (ISO 14001, OSHAS 18001) by an accredited certifying organism?
(Provide copy of the certificate)
N/A Yes No
Do you undertake formal risk assessments of your activities? (Provide copy of your last risk assessment)
N/A Yes No
Has Your Company designed a specific Emergency Response Plan? (Provide copy of the plan and / or drill
records)
N/A Yes No
Do you keep records for Incident / Injury investigation and statistics? (Provide an example)
N/A Yes No
Do you monitor HSE KPIs? (Provide copy of the statistics)
N/A Yes No
4.5. Training
Does a Q-HSE training program exist, covering all your activities and concerning all your employees?
N/A Yes No
Does the training program cover?:
First aid N/A Yes No
Fire fightinng N/A Yes No
Dangerous Goods management N/A Yes No
Personnel Protective Equipment N/A Yes No
Are these trainings recorded?
N/A Yes No
This document must be updated at least once a year and at each major change occuring at
supplier.

Name Position Date Signature + Stamp

Questionnaire
prepared by

Supplier’s Top
Management