Ministry of Public Health

‫وزارة الصحة العامة‬

Oniza Street, Next Civil Defense Round
Contracts & Procurement Department
‫إدارة العـــقـــــــود والـمـشـــــــــــــتريــات‬

PLEASE COMPLETE THIS FORM AND SEND BACK TO MANAGER, PROCUREMENT SECTION
LOCAL SUPPLIER REGISTRATION FORM
_______________________________________________________________________

1.0 COMPANY PROFILE:

1.1 Name of company………………………………………………………………………………………………………………………………………………….

1.2 Street Address: ………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………….

1.3 P.O. Box No: ………………………………………………………………………………………………………………………………………………............

1.4 Telephone No: ……………………………………………………………………………………………………………………………………………………….

1.5 Fax NO: ………………………………………………………………………………………………………………………………………………………………….

1.6 Email Address: ……………………………………………………………………………………………………………………………………………………….

1.7 Web site address (if available) …………………………………………………………………………......................................................

1.8 Company Rep(s) …………………………………………………………………………………………………………………………………………………….

1.9 Rep Full Contact Address: ………………………………………………………………………………………………………………………………………

Note: -

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Based on the Tender Law No 24 for the year 2015 and the Ministry of finance announcement, all companies
must be registered and classified in the Ministry of finance before buying any tender documents from any
governmental organization.

1.10 LIST OF MAJOR SHAREHOLDER:

(With Business Contact Addresses as Mobile, Telephone or email)
 ……………………………………………………………………………………………………………….
 ……………………………………………………………………………………………………………….
 ……………………………………………………………………………………………………………….
 ……………………………………………………………………………………………………………….
1.11 BOARD OF DIRECTORS:
(With Business Contact Addresses as Mobile, Telephone or email)
 ……………………………………………………………………………………………………………….
 ……………………………………………………………………………………………………………….
 ……………………………………………………………………………………………………………….
 ……………………………………………………………………………………………………………….
 ……………………………………………………………………………………………………………….
1.12 MAIN BUSINESS ACTIVITES:
(i) …………………………………………………………………. Since……………………………
(ii) …………………………………………………………………. Since…………………………… (iii)
………………………………………………………………… Since……………………………
(iv) ………………………………………………………………… Since…………………………… (v)
……………………………………………………………….... Since……………………………
2.0 MARK STATUS OF BUSINESS:
So l e A gen t Di st ri b ut o r Ot h er s (pl eas e sp ec i f y)
Ret ai l er Man u f ac t ur er
3.0 BUSINESS REPRESENTED:
Product Name Manufacturer Name Country Of Origin

Continue on a separate sheet if necessary.

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4.0 IF YOU ARE SERVICE PROVIDER, PLEASE STATE TYPE OF SERVICE BELOW:
……………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………..
5.0 COMPANY PROFILE
Please, provide company profile, Leaflet and Brochures etc…
6.0 BANK DETALIS: ……………………………………………………………………………………………………………………………………
7.0 SUPPORTING DOCUMENTS REQUIRED:

7.1 Commercial Registration Number: …………………… Validity Date: ………………………

(Copy of registration document is required)

7.2 License Number: ……………………. Validity Date: ……………………..

(Copy of Municipal License is required)

7.3 Tax Card Number: …………………… Validity Date……………………..

(Copy of Tax Card is required)

7.4 Classification Certificate (from Ministry of finance) Number: …………………… Validity Date……………………..
(Copy of Classification certificate is required)

7.5 Qatar Chamber of Commerce Membership No: …………………….

7.6 Copy of (ISO) Certificate (if available).

7.7 Letter of authorization (If sole agent or distributor)

7.8 Past experience supporting documents.

Note: -
 All Supporting Documents under S. N. 7.0 are essential.
 Renewed documents under S.N 7.1,7.2,7.3,7.4 should be submitted yearly to
Ministry of Public Health, Procurement Section.

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8.0 Details of contracts/ purchase orders for last 3 years (if any).
Hard copy of past contracts or purchase orders is essentially required.
No Sco p e o f W or k Co nt r ac t /PO Val u e Cli en t N ame
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9.0 DECLARATION
We hereby certify that the above particulars are true and correct and accept that MOPH has the right to verify as
and when required all documents and details given as part of this submission .

9.1 Name: …………………………………………………………………………………………………………………………

9.2 Title: ……………………………………………………………………………………………………………………………

9.3 Signature…………………………………………………………………………………………………………………….

9.4 Date: ……………………………………………………………………………................................................

9.5 Official Company Stamp: …………………………………………………………………………………………….

OFFICIAL USE ONLY

Initialed by : ____________________________________________

Approved by: ____________________________________________

Date : _______________________________________________________________
Manager, Contracts & Procurement Department

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