Vendor Registration Form 4x5r6b

Essar Refinery Integrated Management System

Vendor Registration Form 1.Corporate Information Essar Oil Ltd. Qutbi Iron & Scale Mart

Name Of Company : Address :

1182, Pankornaka, Ahmedabad - 380001

City :

Ahmedabad

State :

Postal Code :

380001

Gujarat

Country :

India

Phone 1.

+91-79-25321152

Fax No.2:

+91-79-25382652

Phone 2.

+91-79-25353728

Email:

Fax No 1

Website :

Person Name : Mobile No. :

[email protected]

Jujar A. Rangwala

1) +91-9879154652

2) +91-9227617352

2. Vendor Type (Pl tick in the box) 3. Tax Type (Pl tick in the box ) 1. Chemical / Catalyst / Petroleum product supplier 2. Consumable Material & Spares Supplier 3. Transporter 4. Contractor / Service Provider 5. Government / Statutory Body 6. Manufacturer

3. Industry Type ( Pl tick

1. VAT ed - Raw Material supplier 2. VAT ed - Capital Goods Supplier 3. CST Supplier 4. VAT Un-d Vendor

in the box)

1. Public Sector Unit 2. Private Business 3. Dealer 4. Catalyst Supplier 5. Chemical Supplier 6. Lube Supplier 7. Import Vendor / Foreign Supplier 8. Cement Supplier

10. NSIC ed Supplier 11. Contractor 12. Civil Service/Job 13. Electrical Service/Job 14. Instrumentation/Electronics Service 15. Mechanical Service/Job 16. IT & Telecommunication Supplier 17. Raw material supplier/Govt. manufacturer

9. Supplier cum trader

18. Tor - Steel & Structural

4. Bank Details Country of Bank :

India

Bank Name :

Address : PO. Box. 101, Fuvara, Gandhi Road

Bank of Baroda

Bannk No. : Swift Code ( If Applicable)

03280200003146 NA

Bank Accounut Type: BIC (If Applicable)

Current

5. Taxation Details. ( Kindly submit the photocopies of above certificates. ) Vendor ECC No.: Excise Registration No. Excise Range : Excise Divison : LST NO. : LST Date.: PAN No. :

Excise Commissionarate : CST No. : CST Date : VAT Reg. No. VAT Reg. Date.: Excise Indicator :

24570800243 30-06-1986 24070800243 1/7/2002 Not Applicable

MSMED (Micro, Small & Medium Enterprise) Status (If yes, please give details with the copy of certificate) : Service Tax Registration : With Holding Tax Type (As Applicable) :

6. Financial Information 2007-2008 1 Turnover 2 Profit After tax 3 Fixed Assets 4 Current Assets 5 Current Liablities DOC No

Rev No

EOL/COMM/P&C/R003

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2008-2009

2009-2010

7. List of Major customers

Sr. no

Customer

Description of products suppliedTotal billing in last financial year (Rs.)

1 2 3 4 5 8.Organisation Strength

Managerial Staff Supervisory Staff Skilled Labour Unskilled Labour 9. List of Testing Facilities owned, if applicable

S. No.

Equipment Description

Accuracy & Range

Last Calibration Date

1 2 3 10.List of Manufacturing Facilities ownes, if applicable: S. No.

Description of Machine & Make

Accuracy & Range

No of Machines Installed

1 2 3 4 5 11. Quality System Particulars 1 Is company ISO 9000/ ISO 14000 accredited

Yes /No (If Yes, Enclose copy of certificates)

2 System for Customer Satisfaction Rating ,Process Control , Control of Non Conformities & Measuring and Test Instruments and Conformance to safety requirements exists

Yes / No

( If Yes , Enclose a brief of the systems )

We hear By declare that all the information required to be furnished for registration / enlistment has been filled in correctly.       

Signature and Seal of the CEO Of the Company. DOC No

Rev No

EOL/COMM/P&C/R003

0