PREQUALIFICATION (PQ) DOCUMENT FOR

CIVIL, METAL,
MECHANICAL ELECTRICAL, TRANSMISSION,
CONSTRUCTION
ERECTION AND
COMMISSIONING OF

KLAAI MINI HYDRO POWER PLANT DEVELOPMENTS

PROJECT (2 X 1,3 MW)

REJANG LEBONG -
BENGKULU No :
KLA/YK/01-1-3/001

February 2016
 Table of
Content

Table of Content
Abbreviation and Meaning Perception
1. Project Description
2. Scope of Works
3. Prequalification Process Time Schedule
4. Prequalification Procedure
5. Qualification Criteria
6. JO/JV/Consortium
7. Confict of Interest
8. Update Information
9. General Requirement
10. Apendix
10.1. Appendict Table of Content
10.2. Form 1 - Letter of Application
10.3. Form 2 - Integrity Statement Letter
10.4. Form 3 - General Information, Company Profile and
Attachment
10.5. Form 4 - Subcontractor agreement
10.6. Form 5 - General experience record
10.7. Certificates for previous experience record
10.8. Form 6 - Details of experience record of EPCC of mechanic
civil, metal, al
electrical, transmission, construction erection and commisioning
works
10.9. Form 7 - Details of experience record of EPCC Subcontractor of
civil, metal, mechanical electrical, transmission, construction
erection and commisioning works
10.10. Form 8 - Details of contract of construction erection of turbine
and generator of similar nature and complexity
10.11. Form 9 Details of contract of transmission protection relays of
similar nature and complexity
10.12. Form 10 Details of technical experience of transmission line and
installation
10.13. Certificate of successful operation record of transmission line and
installation
10.14. Certificates for ISO 9001
10.15. Form 11 - Historical financial performance
10.16. Form 12 - Audited financial statement in 3 years
10.17. Form 13 - Average annual turnover
10.18. Form 14 - Litigation history
10.19. MOU of JO/JV/Consortium

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 Abbreviation and Meaning Perception

The following words, abbreviations shall have the meaning hereby assigned,
except where the context otherwise requires.

The application submission for prequalification phase as

Application a Bidder for :
The Works of Civil, Metal, Mechanical Electrical,
Construction
Applicant shall use to apply for this prequalification
Application Forms
document. A set of forms are attached
A Single firm or JO/JV Consortium which expressing
Applicant to apply and
submit a PQ proposal as Bidder for : The Works of
Civil, Metal, Mechanical Electrical, Construction Erection
COD Commercial Operation Date

The date of fulfilment of all conditions stated in EPC

Effective Date Contract, upon which the EPC Contract shall come into
full force and effect, and the
period until time for completion shall be counted from.
A company which has experiences in sectors of
EPCC HydroElectrical Power
Plant works using combinedof Engineering,
Procurement, Construction and Commisioning in
EPCC Contract the EPCC contract of the Project

MHEPP A Mini Hydro Electric Power Plant

Owner The Owner means PT Klaai Dendan Lestari

A member or members of the JV/JO/Consortium other

Partner
than the Prime
Partner
All documents which consist of INVITATION FOR
Prequalification
PREQUALIFICATION, INSTRUCTIONS TO
Document
APPLICANTS and
APPENDICES
The Mini Hydro Electric Power Plant (MHEPP) owned
Project by PT Klaai
Dendan Lestari with capacity design 2 x 1,3 MW.
Klaai MHEPP is located at Rejang Lebong District,
Subcontractor for Civil, Metal Works,
Specialist
Mechanical Electrical, Transmission,
Subcontractor
Construction Erection and Commisioning
All works necessary to complete the Project
together with 20kV
Works
transmission line facilities, including engineering
design, manufacturing, procurement, construction
erection, tests, commissioning and project management.

ii
1. Project Description

1.1. Profle Company

PT Klaai Dendan Lestari is located in Jl. Boulevard Gading
Serpong Blok M 5/3
Summarecon Serpong Tangerang, 15810. PT Klaai Dendan
Lestari is company engaged in mini hydro power plant
development bussiness.

1.2 Power Capacity

. - Design : 2 x 1,3 MW
Capacity
- Ownership : PT Klaai Dendan
Lestari

1.3. General Description

Mini Hydro Electric Power Plants (MHEPP) Klaai obtain water energy
by utilizing the fow of River Klaai which is a tributary branch
upstream to the River Musi. The MHEPP Klaai project description
can be described as follows:

- Weir height : 4m
- Waterway length : 1130 m
- Penstock length : 275 m
- Turbines type : Francis turbines

1.4. Project Location

MHEPP Klaai is located on Klaai Rivers Stream Area,
Geographically located at the position:
- Power House : 10231'33.93" BT 324'8.30" LS
- Weir : 10230'52.4" BT 323'56.4" LS

And administratively,
Located at:
- Village : Bandung Marga
- Sub-District : Bermani Ulu Raya
- Districts : Rejang Lebong
- Province : Bengkulu

Achieving the location can be reached from the city of

Bengkulu by four wheel vehicle toward Curup, the district capital
Rejang Lebong (Curup) as far as 90 km, the Asphalt road conditions
and travel time of approximately 2.5 hours. From Curup heading to
Bandung Marga village is 10 km by road condition class III, then go to
the location project MHEPP Klaai is 300 m from the road by foot or
vehicle two wheels vehicle. Distance locations Intake (weir)

1
upstream to the location of the Central Building is 1.5 km to the
through road with four-wheeled vehicles. Location casing
200 m from the edge of
the road.

2
 Picture 1.1 : Bandung Marga Village Road and road
to Weir zone

Picture 1.2 : MHEPP Klaai

map

1.5. Transportation System to Site Project

- Bengkulu Port
Bengkulu port is a port in West Sumatra within second class that
can be docked by vessels. For transportation of Turbine and
Generator, can utilize this Bengkulu Port or the other way can be
used land transport from Jakarta - Lampung - and Bengkulu
through West Coast Province Roads.

- Bengkulu Airport
The airport Bengkulu named Fatmawati-Soekarno Airport located
in the eastern city of Bengkulu. To reach the project site for
mobilization of personnel, can be reached by traveling overland
from the Bengkulu airport to the Rejang Lebong District or famous
name as known as Curup. The distance between the city of
Bengkulu city - Rejang Lebong about 80 km. The distance from
Rejang Lebong city to the project site about 12 km.

- Equipment Transportation
To transport of heavy equipment and mobilization heavy vehicles,

3
and other transportation required on site project will be made in
early a construction access road. The road will be compacted and
should be able to withstand heavy loads of large vehicles passing

4
2. Scope of Works
Categorization scope of work on this
project is :
- The works of civil, metal, mechanical electrical, transmission,
installation and commisioning

2.1. MHEPP Klaai civil, metal, mechanical electrical,

construction erection and commisioning works

2.1.1. Civil Works

Weir
- Main Weir and Accessories
- Flushing facility
- Intake facility
- Trashrack

Water Way
- Main Water Way and Accessories
- Sand Trap and Accessories
- Spillway

Forebay
- Main Forbay and Accessories
- Spill Way
- Fencing

Penstock
- Penstock foundation and supports

Power House
- Power house steel structure
- Walls and room
- Turbine and Generator foundation
- Standby Generator Room
- UPS and Battery Room
- Control room
- Workshop room
- Fencing
- Other facilities

Tail race
- Tail race and water level control

Switch Yard
- Switch yard area
- Transformator foundation
- Local control
- Fencing

5
2.1.2. Metal Works

Metal works at Weir area

Metal works at Waterway
area Metal works at
Forebay area
Penstock metal works and accessories
Metal works at Power house and turbine area
Metal works at Tail race area
Metal works at Switch yard area

2.1.3. Mechanical and Electrical

M/E at Weir area

M/E at Forebay area
M/E at Powerhouse area
M/E generally
- Lighting system
- Lightning protection system
- Grounding system
- Air conditioning system
- Fire extinguisher system
- Communication tools system
- Cable and cable tray
- Plumbing system
- Sanitation system
- Control system
- Overhead crane and control system

2.1.4. Civil Building and

Utilities
- Civil building
- Utilities Water system
- Security gate
- Roads and utilities

2.1.5 Transmission Line

20kV
- Transmission line and poles
- Transmission line, accessories and installation

6
3. Prequalification Process Time Schedule
Activi Time Schedule Description
ty
1 PQ invitation letter 11 - 12 January -
2016 At 08 AM 16.00
PQ register and pick PM
2 12 & 15 February
up PQ
2016 Address : Plaza
docume
nt Summarecon
At 14.00
3 Elucidation meeting 17 February 2016 PM
Address : Plaza
17 February - 26 Summarecon
Latest schedule at 12
4 Request for clarification or
February 2016 February, 16.00 PM
queries
The queries answer
Companys response to
5 2 Maret 2016 will be sent by email
request for
to all
clarification/queries
participan
Latest closing for
PQ
6 PQ document submittion 4 February 2016 submittion at 16
February
2016, 03.00 PM.
Address : Plaza

4. Prequalification Procedure
4.1. General
Applicants who are interested to participate in the pre-qualification
will only be accepted by the project owner if proposing the official
letter as shown in the form of appendix of this document. Official
letter must be accompanied by supporting documents needed to
process this prequalification. Prequalification submission official
letter must be signed by the authorities which is named in the Deed
of Establishment or can also be represented by who have gained the
power attorney to sign the official letter from the applicant company
and evidenced by a letter of authority signed the letter.

4.2. The date of submission of prequalification application

Applicants should submit a Prequalification proposal along with the
supporting documents not later than schedule due date as stated in
point 3 above

4.3. Requirements for pre-qualification

Applicants must submit a prequalification application in the form of a
single entity, or can also be JO / JV consortium forms. If the
applicant proposed a prequalification application in the form JO / JV
consortium, then in this case must be supported by a letter of
agreement or MoU of JO / JV consortium where it will a clear the
share portion composition and signed by the consortium leader.
In the case of the applicant submit a prequalification application in
7
the form of a single entity, the submission of prequalification
application letter is made on the

8
 official letterhead companies and must be signed on the stamp and
copping with affixed stamp company applicants.

4.4. Specialist Subcontractor

If Applicants in which to do the job will be supported by a specialist
subcontractor, then in this case the applicant must include the name
of its specialist Subcontractor and experiences that be proved
by evidence of an authentic experience in accordance with the
requirements applicable to this pre-qualification document.

4.5. Queries
Any queries shall be submitted by the Applicant on the formal
letterhead of the Applicant that shall indicate the Applicants name
and mailing address in PDF format. The following shall be clearly
marked on pages:
Questionnaire regarding the
prequalification for:
Klaai MHEPP Project for civil, metal, mechanical electrical,
transmission, construction erection and commissioning works
Queries submission must be directed
send to :
PT Klaai Dendan
Lestari
Plaza Summarecon Serpong Lt
3 Unit R.304
Jl. Boulevard Gading Serpong Blok M 5/3 Summarecon
Serpong Tangerang, 15810
Attention : Mr. Yogi
Adhi Satria
Mobile: 081222226030 / email :
yogiadisatria@gmail.com

Queries submission are not allowed passed through of schedule due

date as specified in point 3 above. Queries received after this date,
at the discretion of the Owner, will not be acknowledged nor
Responded to by the Owner. The name and mailing address of the
applicant who send the queries shall be clearly marked on the
letterhead.
A copy of all queries, together with the answers of the Owner will be
issued not later than 3 (two) days after the last schedule of
submission of the question, The queries answer will be sent to all
applicants who have formally informed the Owner of their intention
to submit an Application.

4.6. Content of Applications

All the information requested for prequalification shall be answered
in the English/Indonesian language. Where information is provided in
9
another language, it shall be accompanied by a translation into
English/Indonesian language, which will prevail and will be used for
interpreting the information.
Failure to provide information that is essential to evaluate the
Applicant's qualifications, or to provide timely clarification or
substantiation of the information supplied, may result in
disqualification of the Applicant.

10
4.7. Completion, Initialing and Signing
The Applicant shall prepare all Application Forms by using the
Hard Copies of the forms which will be attached to this
Prequalification Document.
If any Application Form or any part of an Application Form does not
apply by the Applicant, then the Applicant shall write not
applicable on the relevant Form or part, and initial the page.
All pages of the Application, including all forms, added pages and
insertions shall be initialed at the bottom by the Applicant.
Full details including signature of the Applicant, name and position
shall be provided in the required spaces, at the end of the relevant
Forms.

4.8. Copies
Applicants shall submit two (2) sets of their Application, comprising
one (1) original and one (1) copies.
Each set shall be clearly marked ORIGINAL or COPY. The
original shall take precedence in case of any discrepancy.

4.9. Additional or Supplementary Submissions

Submission of additional or supplementary information other than
that specifically requested by the official Application Forms is not
required. However if the Applicant considers that further information
will assist with responses to the requirements of the Application, then
such additional information may be included but only as an
attachment to the respective Form to which the Applicant considers
the information to relate. Separate additional, supplementary or
alternative submissions will not be taken into consideration by the
Owner.

4.10. Submission of Applications

Application of the Prequalification submission to be filled in an
envelope with a letter marking on the top right corner of the
envelope as follows :
- Klaai Mini Hydro Electric Power Plant Project for Civil,
Metal, Mechanical
Electrical, Transmission, Construction Erection and Commissioning
Works. Submission of the Applications for prequalification must
be received in sealed
envelopes, either delivered by hand, courier or by registered mail
to the following
addres
s:
APPLICATION TO
PREQUALIFY :
TO
:

11
PT. Klaai Dendan
Lestari
Attention : Mr.
Kennard Rusali
Email Address:
kennardrusali@gmail.com
Plaza Summarecon Serpong Lt
3 Unit R.304
Jl. Boulevard Gading Serpong Blok M 5/3 Summarecon
Serpong Tangerang, 15810
Contact Person : Mobile: 081222226030 / email :
yogiadisatria@gmail.com (Mr. Yogi Adhi Satria)

12
 The name and mailing address of the Applicant shall be clearly
marked on the envelope.
Submission shall be made and officially received as such by the
Owner not later than
15.00 Western Indonesia Standard Time (WIST) as follow schedule at
point 3 above. The Owner reserves the right to accept or reject
late Applications. The Applicants
who have confirmed in writing to the Owner their intention to submit
an Application,
but who do not submit the Application by the above time and date
will be deemed to have withdrawn from the prequalification process.

5. Qualification Criteria
5.1. Prequalification will be based on meeting all the following minimum
pass/fail criteria regarding the Applicant's general and particular
experience and financial position, as demonstrated by the Applicant's
responses in the forms attached to the Letter of Application. The
Owner reserves the right to waive minor deviations if they do not
materially affect the capability of an Applicant to perform the
contract.

5.2. General Experience

The Applicant or their Specialist Subcontractor shall meet the
following minimum criteria:

5.2.1. Previous Experience in Civil, Metal, Mechanical Electrical,

Transmission, Construction Erection and Commissioning
The Applicant shall able to demonstrate, using Application
Form 5, general experience records of the Single Entity or a
member of JO/JV/Consortium showing that it has successfully
completed and participated, in projects of a nature and
complexity comparable to the Works complying with the
following minimum requirements.

5.2.1.1. At least two (2) experiences of the Single

Entity or JO/JV/Consortium of Engineering,
Procurement, Construction and Commissioning
(EPCC) of hydro power plant projects in Civil,
Metal, Mechanical Electrical and Installation and
Commissioning in Indonesia or outside of its home
countries from 2006 until 2016 (Year of COD) and at
least one (1) of the projects shall be in Indonesia
area, and,

5.2.1.2. Among those projects in point 5.2.1.1 above, the

contract price of EPC projects at least one (1) of the
projects shall be a five million US dollar ($5 M) or
more.

13
5.2.1.3. The Applicant shall demonstrate with full evidence
that its Single Entity or a member of the
JO/JV/consortium of Engineering, Procurement,
Construction and Commissioning (EPCC) of hydro
power projects in Civil, Metal, Mechanical Electrical,
Transmission, Construction Erection and
Commisioning have the following required
experiences using Application Form 6

14
 5.2.1.4. At least two (2) experiences of the spesific Single
Entity or JO/JV/Consortium of Engineering,
Procurement, Construction and Commissioning
(EPCC) of Subcontractor in Civil, Metal, Mechanical
Electrical, Transmission, Construction Erection and
Commisioning in Indonesia from 2006 until 2016
(Year of COD), and,

5.2.1.5. The Applicant shall demonstrate with full evidence

that its Single Entity or a member of the
JO/JV/Consortium of Engineering Procurement,
Construction and Commissioning (EPCC) of
subcontractor have the following required
experiences using Application Forms 7

5.3. Financial Position

The Applicant shall demonstrate their financial capability, using
Application Forms 10,
11 and 12. Where necessary, the Owner will make inquiries with
the Applicant's bankers. The minimum requirements are as follows.

5.3.1. Historical Financial Performance:

Submission of audited balance sheets and income statements
or, if not required by the law of the Applicants country, other
financial statements acceptable to the Owner, for the last
three (3) years 2013, 2014, 2015 to demonstrate the
current soundness of the Applicants financial position and its
long-term profitability. As a minimum, an Applicants net
worth in the latest balance sheet calculated as the
difference between the total assets and total liabilities
should be positive.

5.3.2. Average Annual Turnover: Minimum average annual

turnover of fifty million US dollar ($5 M) calculated as total
certified payments received for contracts in progress or
completed, within the last of 2013, 2014, 2015.

5.4. Quality Assurance and Environmental Management System

The Applicant shall demonstrate their Quality Certificate, Health
Safety Environment
(HSE), OSHAS, ISO and other certificates according the management
and quality.

6. JO/JV/Consortium
6.1. The formation of a JO/JV/Consortium after prequalification, and any
change in a pre- qualified JO/JV/Consortium, will be subject to the
written approval of the Owner prior to the deadline for submission
15
of Tender. Such approval may be denied if (i) Partners withdraw from
a JO/JV/Consortium and the remaining Partners do not meet the
qualifying requirements; (ii) the new Partners to a JO/JV/Consortium
are not qualified, individually or as another JO/JV/Consortium; or (iii)
in the opinion of the Owner, a substantial reduction in competition
may result.

16
 6.2. In the case of voluntarily formed JO/JV/Consortium, the Applications
should only be made where all Parties to the JO/JV/Consortium are
jointly and severally liable for the execution and completion of all of
the Works. Any Application from a JO/JV/Consortium shall be signed
so as to legally bind all Partners, jointly and severally. Such
Application shall be submitted with a copy of the joint venture
agreement.

6.3. The prequalification of a joint venture does not prequalify any of its
partners individually or as a partner in any other joint venture or
association. In case of dissolution of a joint venture, the
constituent firms will not be permitted to prequalify.

6.4. Minimum Share of the consortium leader of JO/JV/consortium

must have at least
40% share of the JO/JV/Consortium.

7. Confict of Interest
The Applicant (including all members of a joint venture) shall not be one
of the following:
7.1. A firm or an organization which has been engaged by Owner to
provide consulting services for the preparation related to
procurement for or implementation of this project;

7.2. Any association/affiliates (inclusive of parent firm) of a firm or an

organization mentioned in subparagraph (a) above; or

7.3. A firm or an organization who lends, or temporarily seconds its

personnel to firms or organizations which are engaged in consulting
services for the preparation related to procurement for or
implementation of the project, if the personnel would be
involved in any capacity of the same project.

8. Update Information
Applicants shall be required to update the financial information used for
prequalification at the time of submitting their Tenders and to confirm
their continued compliance with the qualification criteria.

9. General Requirement
9.1. Only the Applicants that have been qualified under this procedure
will be invited to
Tender.
9.2. Applicants will be advised by the Owner in writing by facsimile or
e-mail, not later than the date referred to in the Invitation for
Prequalification, of the result of their Applications, without being
assigned any reason for the Owner's decision.
9.3. All the Applications and enclosures will be treated by the
17
 Owner as strictly confidential and will be used only for the purpose
that they are intended.
9.4. The Applications will not be returned in the event of either
acceptance or rejection.

18
 10. Apendix
10.1. Appendict Table of
Content

10.2. Form 1 - Letter of Application

10.3. Form 2 - Integrity Statement Letter
10.4. Form 3 - General Information, Company Profile and Attachment
10.5. Form 4 - Subcontractor agreement
10.6. Form 5 - General experience record
10.7. Certificates of previous experience record
Form 6 - Details of experience record of EPCC of civil, metal,
10.8.
mechanical electrical,
transmission, construction
Form 7 - Details erectionrecord
of experience and commissioning
of EPCC Subcontractor of civil,
10.9.
metal, mechanical
electrical, transmission,
Form 8 - Details construction
of contracts erection erection
of construction and commissioning
of turbine and
10.10.
generator of similar
nature
Form 9and complexity
- Details of contracts of transmission protection relays of
10.11.
similar nature and
10.12. complexity
Form 10 - Details of technical experience of transmission line and installation
10.13. Certificate of successful operation record of transmission line and installation
10.14. Certificates for ISO 9001
10.15. Form 11 - Historical financial performance
10.16. Form 12 - Audited financial statement in 3 years
10.17. Form 13 - Average annual turnover
10.18. Form 14 - Litigation history
10.19. MOU of JO/JV/Consortium

19
10.2. Form 1 - Letter of Application

[letterhead paper of the Applicant, including full postal address,

telephone no, fax no, telex no., and cable address]

Letter of
Application

Date:............................

To PT Klaai Dendan Lestari

President Director
Plaza Summarecon Serpong Lt 3 Unit R.304
Jl. Boulevard Gading Serpong Blok M 5/3 Summarecon Serpong
Tangerang, 15810

Dear Sir,

1. Being duly authorized to represent and act on behalf of

................................... (hereinafter referred to as the Applicant),
and having reviewed and fully understood all of the
prequalification information provided, the undersigned hereby
apply to be prequalified by yourselves as a potential contractor for
Civil, Metal, Mechanical Electrical, Transmission, Construction
Erection and Commissioning for Klaai Mini Hydro Electric Power
Plant Project (2 x 1,3 MW) :

2. Attached to this letter are copies of original documents defining:

(a) the Applicant's legal status, and

(b) the principal place of business.

3. The Owner and its authorized representatives are hereby

authorized to conduct any inquiries or investigations to verify the
statements, documents, and information submitted in connection
with this application, and to seek clarification from our bankers and
clients regarding any financial and technical aspects. This Letter of
Application will also serve as authorization to any individual or
authorized representative of any institution referred to in the
supporting information, to provide such information deemed
necessary and as requested yourself to verify statements and
information provided in this application, such as the resources,
experience, and competence of the Applicant.

4. The Owner and its authorized representatives may contact the

following persons for further information:
 General and managerial inquiries
Contact 1 Telephone 1
E-mail address 1
Contact 2 Telephone 2
E-mail address 2

Personnel inquiries
Contact 1 Telephone 1
E-mail address 1
Contact 2 Telephone 2
E-mail address 2

Technical inquiries (Civil Works / Metal works)

Contact 1 Telephone 1
E-mail address 1
Contact 2 Telephone 2
E-mail address 2
Technical inquiries (E/M Works)
Contact 1 Telephone 1
E-mail address 1
Contact 2 Telephone 2
E-mail address 2
Technical inquiries (T/L Works)
Contact 1 Telephone 1
E-mail address 1
Contact 2 Telephone 2
E-mail address 2

Financial inquiries
Contact 1 Telephone 1
E-mail address 1
Contact 2 Telephone 2
E-mail address 2

5. This application is made with the full understanding that:

(a) Selection of a contractor among prequalified applicants

will be subject to verification of all information submitted
for prequalification at the time of the selection;

(b) The Owner and/or representatives reserve the right to:

ammend the scope and value of any contracts under

this project; in such event, the contractor will only be
decided from prequalified applicants who meet the
revised requirements; and

reject or accept late Applications,

cancel the prequalification process, and reject all Applications.

 (c) the Owner and/or representatives shall not be liable for
any such actions and shall be under no obligation to
inform the Applicant of the grounds for them.

6. The undersigned declare that the statements made and the

information provided in the duly completed application are
complete, true, and correct in every detail.

Signed

Name

For and on behalf of (name of Applicant)

10.3. Form 2 - Integrity Statement Letter

I, the undersigned below :

Name : _[name of authorized

representative a business entity]

No. License Identity : _[ filled by No.KTP/ SIM/ Passport]

Position :

Acting for and on behalf of : PT/CV

In order to procure for: The civil, metal, mechanical electrical, transmission

and commissioning works for Klaai Mini Hydro Power Plant Project (2 x 1,3
MW) hereby declare :

1. Have no intention doing corruption, collusion and nepotism (KKN);

2. Will follow the procurement process cleanly, transparently , and

professionally to

provide the best work in accordance with laws and regulations;

3. If the integrity page is violated, willing to accept an administrative

sanction, accept sanctions
inclusion in the entering on Black List, sued civilly and or criminally reported.

_[Place],

[Date] [Name of

PT/CV PQ]

[Signature]

[Name]

[Position]
 10.4. Form 3 - General Information, Company Profle and Attachment

General
Information

1. Position in the
Applicant
Single Entity
Prime Partner
Partner
Specialist Subcontractor
2. Name of Applicant / Name of Single Entity, Prime Partner, Partner or Specialist
Subcontractor
( * In case the name of the Applicant and the name of the firm are different, the
both shall be written down. )

3. Head office address

4. Telephone Contact

5. Fax E-mail address

6. Place of incorporation / registration Year of incorporation / registration

Note:

*) Single Entity, Prime Partner, Partner and Specialist

Subcontractor applying for prequalification are requested to
complete the information in this form.
 10.5. Form 4 - Subcontractor agreement

Subcontractor Agreement

TO:
The undersigned of this declaration agreed to be proposed as
a Specialist
Subcontractor by [name of the firm] with regard to following
works of Civil, Metal, Mechanical Electrical, Transmission, Construction
Erection and Commissiong for Klaai Hydroelectric Power Plant Project (2 x
1,3 MW)

Give inputs, names and positions of the proposed Specialist

Subcontractor
Representatives, as well as organization's names
and addresses:

Input: Civil Works /

Metal Works /
Turbine /
Generator /
Installation of Turbine and Generator /
Transformer /
Switch gear (LV-MV) and Circuit breaker
Transmission Line protection relay /
Transmission Line

Name: Signature:

Position: Date:

Representing:
10.6. Form 5 - General experience record

Applicant name : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Project : The Klaai Mini Hydro Electric Power Plant (2 x 1,3 MW)

COD Year From 2006 to 2016

Project Owner Contrac
No Project Name Scope of Works Project t Completio
Name Address Value Contract No
Location n
1. ....... date

Note :
Applicants have to enclose this form with :
- Copy of Contract Head Cover
- Copy of Contract Scope of Works and Prices
- Copy of Certificate of Completion Date
- Please add rows if it is no sufficient

22
10.7. Certificates for Previous Experience Record

PLEASE ATTACH THE CERTIFICATE FOR PREVIOUS EXPERIENCE RECORD

23
10.8. Form 6 - Details of experience record of EPCC of Civil, Metal, Mechanical Electrical, Transmission,
Construction Erection and Commissioning
Works

Applicant name : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Project : The Klaai Mini Hydro Electric Power Plant (2 x 1,3 MW)

COD Year From 2006 to 2016

No Project Name Scope of Works Specification/ Dimension/Capacity/Size Remark
s

*Please add rows if it is no sufficient

24
10.9. Form 7 - Details of experience record of EPCC Subcontractor of Civil, Metal, Mechanical Electrical,
Transmission, Construction Erection and
Commissioning Works

Applicant name : ........................................

Project : The Klaai Mini Hydro Electric Power Plant (2 x 1,3 MW)

COD Year From 2006 to 2016

No Project Name Scope of Works Specification/ Dimension/Capacity/Size Remark
s

*Please add rows if it is no sufficient

25
10.10. Form 8 - Details of contracts of construction erection of turbine and generator of similar nature and
complexity

Applicant name : ........................................

Project : The Klaai Mini Hydro Electric Power Plant (2 x 1,3 MW)

COD Year From 2006 to 2016

Plant Name Country
COD Year Turbine/ Generator Type:
Costumer Turbine/ Generator Specification :
Location of the factory :

Reference number of certificate

Plant Name Country
COD Year Turbine/ Generator Type:
Costumer Turbine/ Generator Specification :
Location of the factory :

Reference number of certificate

Note :
*Please add rows if it is no sufficient

26
10.11. Form 9 - Details of contracts of transmission line protection relays of similar nature and complexity
Applicant name : ........................................
Project : The Klaai Mini Hydro Electric Power Plant (2 x 1,3 MW)

COD Year From 2006 to 2016

Plant Name Country
COD Year Unit Type : Manufacturer Name (model No) Specification :

Costumer Work scope Designing Model Testing

Manufacturing Installing
Supervising for Installation
Site Testing Commissioning
Reference number of certificate
Plant Name Country
COD Year Unit Type : Manufacturer Name (model No) Specification :

Costumer Work scope Designing Model Testing

Manufacturing Installing
Supervising for Installation
Site Testing Commissioning
Reference number of certificate

Note :
*Please add rows if it is no sufficient

27
10.12. Form 10 - Details of technical experience of transmission line accessories and Installation
Applicant name : ........................................
Project : The Klaai Mini Hydro Electric Power Plant (2 x 1,3 MW)

Plant Name Country

COD Year Unit Type : Manufacturer Name (model No) Specification :

Costumer Work scope Designing Model Testing

Manufacturing Installing
Supervising for Installation
Site Testing Commissioning
Reference number of certificate
Plant Name Country
COD Year Unit Type : Manufacturer Name (model No) Specification :

Costumer Work scope Designing Model Testing

Manufacturing Installing
Supervising for Installation
Site Testing Commissioning
Reference number of certificate

Note :
*Please add rows if it is no sufficient

28
10.13. Certificate for Successful Operation Record of Transmission Line accessories and Installation

PLEASE ATTACH THE CERTIFICATE OF SUCCESSFUL

OPERATION RECORD

29
10.14. Certificates for ISO 9001

PLEASE ATTACH THE CERTIFICATE FOR ISO 9001

30
10.15. Form 11 - Historical financial performance
Applicant name : ........................................
Project : The Klaai Mini Hydro Electric Power Plant (2 x 1,3 MW)

Actual previous
Financial three years
information in
USS 201 201 201
Equivalent 3 4 5
1 Total assets
2 Current assets
3 Total liabilities
4 Current liabilities
5 Sale
6 s Profits
Ordinary
7 Profit before taxes
8 Profit after Taxes

Note :
* At the rates of exchange current at the end of each year for the previous three year
*If Necessary, use separate sheets to provide complete bank information. Attaching a copy of the audited balance
sheets and statement and losses

31
10.16. Form 12 - Audited financial statement in 3 years (2013, 2014 and 2015)

Bank information Name of Bank

for the applicant's
bank for the
Employer's inquiries Address of Bank

Telephone Contact name and title

Fax Telex

32
10.17. Form 13 - Average annual turnover
Applicant name : ........................................
Project : The Klaai Mini Hydro Electric Power Plant (2 x 1,3 MW)

Annual turnover data

(construction only)

Yea Turnov US$

r er equivalent
201
3
201
4
201
5

Note:
* The information supplied should be the annual turnover of the Tenderers in terms of the amounts billed to clients for
each year for work in progress corcompleted, converted to U.S. dollars at the rate of exchange at the end of the period
reported.
* Tenderers should not enclose testimonials, certificates, and publicity material with their applications; they will not
be taken into account in the evaluation of qualifications.

33
10.18. Form 14 - Litigation history
Applicant name :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Project : The Klaai Mini Hydro Electric Power Plant (2 x 1,3 MW)

Award FOR or
AGAINST Disputed amount
Year Name of client, cause of litigation, and
Applicants or its matter in dispute (current value,
Specialist US$ equivalent)

34
10.19. MoU of JO/JV/Consortium

PLEASE ATTACH A COPY COVER OF MOU OF JO/JV/CONSORTIUM

35