SCHEDULE 1 – DETAILS OF APPLICANT(S) Name: * Address: * Phone: * Website (if available): Email: * Is Applicant a Company, Partnership or Sole Trader (provide detail): * ABN: * Please detail RELEVANT INSURANCES (detail each): * CERTIFICATE OF CURRENCY (attach each relevant) *
PROPOSED APPROACH TO DELIVERY OF SERVICES, eg. REMOTE, FROM NACCHO OFFICES etc. (provide detail): * PROPOSED SERVICES TO BE PROVIDED & TECHNICAL REQUIREMENTS
Service Providers are to include a statement of no more than one (1) page per Service Category
in their Tender submission that addresses the Technical Requirements set out below.
Tenders will be evaluated in accordance with the following technical sub-criteria:
• the Service Provider's ability to provide the Services in accordance with the Statement of Requirements,
based on the skills, qualifications and/or experience of the Service Provider and/or proposed personnel and subcontractors in delivering the Service Categories tendered for.
• evidence of the Service Provider's previous or comparable experience in delivering the Service Categories
**SELECT ALL CATEGORIES THAT APPLY** * TECHNICAL REQUIREMENT STATEMENT/ S (upload no more than one page for each Service Category selected) *
NOMINATED PERSONNEL TO PROVIDE SERVICE AND AVAILABILITY (list) * RELEVANT EXPERIENCE OF NOMINATED PERSONNEL (list) * RELEVANT CURRICULUM VITAE (attach one for each nominated person) *
REAL OR PERCEIVED CONFLICT OF INTEREST THAT MAY ARISE IF SUCCESSFUL WITH THIS APPLICATION (provide details) * SCHEDULE 2 – FEE SCHEDULE
RATES AND AMOUNTS SHOULD BE EXCLUSIVE OF GST
DETAILS OF DISBURSEMENTS AND OTHER EXPENSES ASSOCIATED WITH THIS PROPOSAL (include estimated costs) * ATTACHMENT OF DISBURSEMENTS AND OTHER EXPENSES (if applicable)
NOMINATED PERSONS INCLUDING THEIR TITLE / POSITION, DAILY & HOURLY RATE ($/hr) – short term Hourly Rate or ($/hr) – longer term (list) * NOMINATED PERSONS ATTACHMENTS (if applicable)
SCHEDULE 3 – STATEMENT OF COMPLIANCE Offer to provide Services 1. The Applicant offers to provide the Services described in the Invitation to Participate in Panel Arrangements for the Provision of Consultancy Services to Support the Coalition of Peaks issued by the National Aboriginal Community Controlled Health Organisation (NACCHO) at the fees and charges tendered in its tender and subject to the terms and conditions of the Invitation. * 2. The Applicant acknowledges that: (a) it has the capacity to offer the Services as described in its tender and there is no restriction under any relevant law to prevent it from making such an offer; (b) it has sufficient financial resources to deliver the Services, including in respect of any guarantees or warranties related to the delivery of those Services; (c) there is no current or impending legal action (either formal proceedings or notification of legal action) which the Applicant is aware that could impact on the financial viability of the Applicant or the delivery of the Services; and (d) it complies with all Conditions for Participation set out in this Invitation to Participate. * Conflict of Interest 3. At the time of submitting its tender, the Applicant has made reasonable enquiries and is not aware of any Conflict of Interest, other than those disclosed in its response in Schedule 1 that exists or may arise in the provision of the Services should the Applicant be successful as a result of this Invitation to Participate process. * Offer Period 4. The Applicant’s offer, as comprised in its tender, remains open for the Offer Period. * 5. The Applicant will notify NACCHO of relevant details if there is any ‘material change’ in the Applicant or the tender after lodgement of this tender. * Compilation of tender 6. The Applicant’s tender has been compiled without the improper assistance of employees or former employees of NACCHO and without the use of illegally obtained information. * 7. Neither the Applicant, nor any of its officers, employees, agents, subDeed of Standing Offerors and/or proposed consortium members (if any), has attempted to, or will attempt to, improperly influence an officer of NACCHO in connection with the preparation or assessment of this tender. * Judicial decisions 8. The Applicant represents that it does not have a judicial decision against it (apart from a decision under appeal) or any resulting order relating to employee entitlements (not including decisions under appeal) where the Applicant has not paid the claim. * Compliance with all Relevant Laws and Regulations 9. The Applicant represents that it is able to meet any Australian standards applicable to the Services. * Compliance with all Relevant Laws and Regulations 10. The Applicant represents that they are compliant will all relevant legislation, laws and regulations of the Commonwealth and any State, Territory, or local authority as these relate to participation in the Panel and will continue to abide by the requirements of these for the period covered by this Invitation. * Confidentiality 11. The Applicant will not, and will ensure that its employees, agents or subcontractors do not, either directly or indirectly record, divulge or communicate to any person any confidential information concerning the affairs of NACCHO or any third party acquired or obtained in the course of preparing a Tender, or any documents, data or information provided by NACCHO and which NACCHO indicates to Applicants is confidential or which Applicants know or ought reasonably know is confidential. * Ethical Dealing 12. The Applicant represents that its tender has been compiled without the improper assistance of any current or former NACCHO officer, employee, contractor or agent and without the use of information obtained unlawfully or in breach of an obligation of confidentiality. * 13. The Applicant represents that it has not: *
This Deed Poll is governed by and is to be construed in accordance with the laws in force in the Australian Capital Territory.
SIGNED, SEALED AND DELIVERED AS A DEED POLL for the benefit of NATIONAL ABORIGINAL COMMUNITY CONTROLLED HEALTH ORGANISATION (NACCHO) FULL NAME OF THE AUTHORISED OFFICER OF THE APPLICANT *