Company Contact Company Overview Insured? YesNo Bonded? YesNo Licensed? YesNo License Number Banking Information Certification * I hereby affirm that all information supplied is true and accurate to the best of my knowledge and belief, and I understand that this information will be considered material in the evaluation of quotations, bids, and proposals. Notice must be given of any change in status impacting the information provided within ten (10) days of said change. Printed/Typed Name Title MrMrsMissDr Date Supplier Conflict Of Interest Declaration All suppliers interested in conducting business with ZIM-TTECH must complete and return the Supplier Conflict of Interest Disclosure Form in order to be eligible to be awarded a contract. Please note that all suppliers are subject to comply with ZIM-TTECH conflict interest policies as stated within the certification section below. If a supplier has a relationship with a ZIM-TTECH official or employee or an immediate family member of ZIM-TTECH official or employee, the supplier shall disclose the information required below. Declaration: I hereby certify that to my knowledge, there is no conflict of interest involving the supplier named below: 1. Does any ZIM-TTECH employee have any direct or indirect ownership or other financial interest in your company or any of its affiliates? YESNO 2. Is any owner, director, or key employee of your company a current or former ZIM-TTECH employee? YESNO 3. Does any owner or director in your company (supplier) have any family relationship with any current ZIM-TTECH employee? YESNO 4. Does any current ZIM-TTECH employee have employee or business relationship with any owner or director of your company? YESNO 5. Have ZIM-TTECH employee been entertained, given gifts or per diems or hamper, participated in any trips, or otherwise been provided any money or other thing of value by your company or any of its affiliates in connection with this scope of work? YESNO Disclosure for Conflict of Interest – Explain all YES answers in the section below. I certify that the information provided is true and correct: YES Name of supplier authorized representative: Date Please attach your Company Profile, Current Tax Clearance and Company Registration Forms Company Profile: Current Tax Clearance: Company Registration: Categories applied for
