Application Form for EOI 1. Organization Name 2. Address (Regd.

Office) : :

2 (a) Premises own/ rented (i) If own provide Tax paid receipt (ii) If rented copy of rent agreement has to be provided. 3. Address (Local Office)

4. Telephone No. & Fax 5. email 6. website 7. Chief of the Organisation 8. Telephone 9. email Id 10. Name of Contact personnel 11. Telephone 12. email ID 13. Type of the Organisation (Public Sector/Limited/Private limited/ Partnership, Proprietary /Society /Any other.) 14. Registration details (enclose certificates) :

: : : : : : : : :

13(a) Photo Id of Directors / Proprietor : :

Company Registration Tax Registration PF Registration ESI Registration Income-tax Registration PAN No (enclose certificate) : :

14(a) Name of the Banker and A/c No 15. Activities of the Company (enclose the Literature/ Brochure /Product Catalogue) Products manufactured IT Solutions developed Services offered Products/service marketed Training Any other activity

16. Details of Quality certification like CMM Level/ ISO Etc. (enclose Certificates) 17. Turnover of the Company for the last 2 years (enclose Balance Sheet). 18. Client List (enclose the List of Clients) 19. No. of Offices/Centers (enclose the list) 20. Total No.of Employees Technical Staff Non-Technical Staff

: : : :

21. KEONICS will follow the Karnataka Transparency in Public Procurement (KTPP) Act 1999 while awarding the work. 22. An amount of Rs.1.00 lakhs only to be paid by DD in favour KEONICS, payable at Bangalore, as non-refundable fee for empanelling the firm. 23. Validity : Initially valid up to 31.3.2011 and to be renewed further up to

31.3.2012, based on the review and performance.

24. All attached copies to be certified as True Copy, signed and sealed by the authorized signatory. 25. Any other additional information the applicant wants to furnish in favour his/their business credentials: (Attach the documents) I hereby declare that the above information is true to the best of my knowledge.

Signature with Name & Seal Place : Date :

Verification: I have verified all the documents furnished along with application form and found the application in order/not acceptable. forwarded/returned to the concerned. The application is

Signature of the Verifying Officer Place : Date :