TENDER OF APPLICATION FORM

To:
Bureau of Procurement,
Humanitarian Aid & Relief For Francophone Africa (HARFA), Trois-Rivières, Canada
Aide Humanitaire Et Soulagement Pour L'Afrique Francophonie (AHSAF), Trois-Rivières, Canada

I/We wish to apply and tender our bid to participate in the tendering/bidding process and to be awarded the contract for the supply
of the below listed products/services to your organization.

SCOPE OF WORK (Details / Description of Products to be supplied or services to render and the Products LOT)

Name of Products/Services: Cassia Cinnamon stick grade Ap………………………………………………………………………..

Quantity: 500 MT……………………………………………………Country of Origin: Indonesia…………………………………

PARTICULARS OF APPLICANT

Company Name: PT Effa Cipta Sejahtera……………………………………………………………………………………………..

Address: Anggrek Loka B7 No.24 Graha Raya Serpong Utara Tangerang Selatan Banten Indonesia………………………………..

Contact Person (Owner/CEO/MD): Eka Immawaty…………………………………………………………………………………...

Office Tel No: +62 82221922251………………………………….. Mobile: +62 82221922251…………………………………….

Email: effa.ciptasejahtera@gmail.com.............................................. Company Reg. No: 0703230070752…………………………...

Year of Est: 2023………………….Number of Employees: 15…….Annual Turnover: USD $ 2.000.000……………………………

Type of Supplier: Manufacturer ( )………Service Provider………..Distributor/wholeseller…………….Agent………………….

(Tick as Aprropriate)
Has the company handled similar project for any organization, government institution/agency before? If yes, supply details:

Yes, we exported to others countries to India and Nigeria and fulfill to locals needed as suplly to agents in Indonesia. ……………

If this contract(s) is/are awarded to you via the Recommendation of Trust (ROT) by your sourcing Agent, what guarantee do you
give in facilitating and executing the contract; and how long would it take your company to complete the contract after your
company has been fully paid?

…………………………………………………………………………………………………………………………………………

Has your company been registered with our Organization as a Qualified Vendor? Not Yet………………………………………….

DECLARATION
I/We accept to complete this Tender Application Form and also understand that only completed form will be valid for consideration.
Any false information declaration given will lead to automatic disqualification of our company from the bidding process and the
eventual award of the contract.

Signature: ……………………. Date : December 22nd 2023………………………………………………..

FOR OFFICE USE ONLY

Name of Evaluator:…………………………………………………………………………………………………………………….

Remarks:………………………………………………………………………………………………………………………………..

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

Signature:................................................................... Date:…………………………………………………………………………...

Tenderers must fill this form appropriately and return with the other requested documents and submit to contact@harfa3r.org