Annex 2 PQ Forms-June 2016 - Final

Annex 2
FORMS FOR PREQUALIFICATION
PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

BERTH 7 REFURBISHMENT AT APM TERMINALS CALLAO
Letter of Application
Form I
Guidance Notes:
NOTE 1: This Form MUST be completed to ensure consideration for the pre-qualification
process (if applicable).
NOTE 2: If the company does NOT wish to be considered for the pre-qualification
phase as one of the Consultants under section 1A, please indicate by placing
a in the box.
NOTE 3:
1.
Placing a in the box will not disqualify the company from participating in the prequalification phase or tender phase as a Sub-contractor to a JV or Consortium.
No supporting documents are required to be submitted with this Expression of
Interest.
Scope selection
The company is to indicate its scope(s) of interest and preference by placing a in the
required boxes. Preference should be numbered 1, 2, . etc., with 1 being companies
preferred scope.
Scope
A)
i)
ii)
iii)
Refurbishment of the marine works-Piers.

Building refurbishment of pier
Equipment refurbishment of pier, consisting of:
Electrical refurbishment
Water supply
firefighting system
pressurized air system
dismantling and deconstruction of old
structures
STATEMENT
Registered Business Name:
Registered Business Address:......................................................................................................
Phone:.................................................................
Fax: .....................................................................
Email: ..................................................................
To:
APM Terminals Callao S.A.

Avenida Contralmirante Raygada N 111 Entrada del Puerto,
Muelle Norte, Callao
Per
Phone:
+511 200 8808
Fax:
Email:
Antonio.franca@apmterminals.com
Page 1/24

Sir:
1.
We hereby apply to be qualified as a bidder for the APMT-C Project.
2.
We authorize the APMT-C or its authorized representatives to conduct any

investigations to verify the statements, documents and information submitted and to
clarify the financial and technical aspects of this application. For this purpose, we hereby
authorize (any public official, engineer, bank, depository, manufacturer, distributor, etc)
or any other person or firm to furnish pertinent information deemed necessary and
requested by APMT-C to verify statements and information provided in this application or
regarding our competence and standing.
3.
The names and positions of persons, who may be contacted for further information, if
required, are as follows:
a) Technical: .................................................................................................................... ;
b) Financial: ......................................................................................................................
c) Personnel:.................................................................................................................... .
4.
We declare that the statements made and the information provided in the duly
completed application are complete, true and correct in every detail.
5.
I, the undersigned, being the authorised signatory of the Applicant (including all partners,
in the case of an Applicant of two or more firms), hereby declare that we have examined
the procurement notice for the tender procedure. If our application is short-listed, we fully
intend to submit a tender to provide the services and works requested in the DesignBuild tender dossier.
6.
We are fully aware that, in the case of an Applicant of two firms, the composition of the
Applicant cannot be modified in the course of the tender procedure. We are also aware
that the partners representing the Applicant would have joint and several liability towards
APMT-C concerning participation in both the above tender procedure and any contract
awarded to us as a result of it.
Page 2/24

Signed on behalf of the Applicant
Name:
Position:
Signature:
..................................................................................
(a person or persons authorised to sign on behalf of the Applicant)
Date:
.....................
Page 3/24
Insert
Name of Applicant/ Partner/ Sub-consultant

BERTH / REFURBISHMENT AT APM TERMINALS CALLAO
General Information
Form II
All individual Applicants and each member of an Applicant consisting of two firms applying for
prequalification must complete the information in this form.
Where the Applicant proposes to employ subcontractors for specialised components of the
works, or for work contents in excess of 15 percent of the value of the whole works, the
following information must also be supplied for the specialist subcontractor(s).
1.
Name of firm:
2.
Place of incorporation/registration:
3.
Head office address:
4.
5.
Year of incorporation/registration:
Telephone:
Contact Person:
Fax:
Telex:
Address of local office or agency (if any):
Telephone:
Contact Person:
Fax:
Telex:
Main lines of business

1.
Since:
2.
Since:
3.
Since:
4.
Since:
Signature:
..................................................................................

Date:
.....................
Page 4/24
Insert

BERTH REFURBISHMENT AT APM TERMINALS CALLAO
Data of Applicants consisting of two firms
1.
Name......................................................................................
2.
Managing board's address..................................................

..................................................................................................
Telex..........................................................
Telephone .........................Fax..................................E-mail.....
3.
Agency in the Republic of Per, if any (in the case of a foreign lead
partner )
Office address...........................................................................
..................................................................................................
Telex..........................................................
Telephone ..............................Fax.........................................
4.
Names of partners
i) ..............................................................................................
ii) ..............................................................................................
iii) ..............................................................................................
Etc. ............................................................................................
5.
Name of lead partner

..................................................................................................
..................................................................................................
6.
Agreement governing the formation of the Applicant consisting of two

or more firms
i) Date of signature: ................................................................
ii) Place: ...................................................................................
iii) A copy of the Agreement on joint and several liability shall be
attached
Proposed proportion of responsibilities between partners (in %) with
indication of the type of the works to be performed by each
..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
..................................................................................................
7.
Signature:
Form III
..................................................................................

Date:
.....................
Page 5/24
Insert

Specialized Subcontractors
Form IV
a.
Please give information about the section of works [e.g. engineering design of maritime structures,
pile repair works, pile installation works, building refurbishment, firefighting system, etc.] and the
names of subcontractors.
b.
Applicant is obliged to nominate at least 2 or 3 specialised subcontractors for each section of work
intended to be subcontracted and to provide a brief summary of previous projects where the
intended sub-contractor has successfully worked with the Applicant.
c.
Take notice that subcontractors with more than 15% of the value of the whole works also have to
provide the requested information in FORMS II & V to VIII separately.
Name of subcontractor
Address
Section of work in this

project
Detailed design of marine
structures (sample)
Detailed design of firefighting

system (sample)
Detailed design of electrical

equipment (sample)
Signature:
..................................................................................
Date:
.....................
Page 6/24
Insert

Financial Data
Form V.a
a.
Applicants, each partner of an Applicant of two or more firms, as well as specialized subcontractors (with a work contents in excess of 15% of the value of the whole works) must provide
financial information to demonstrate that they meet the requirements for prequalification. If
necessary, use separate sheets to provide complete banker information. Attach documents to
demonstrate availability of line of credit, overdraft facilities, or other proof of financial capability. All
such financial performance characteristics or documents shall reflect the financial situation of the
Applicant or member of an Applicant of two or more firms, and shall not include sister or parent
companies.
b.
Financial Data form (Forms V.b to V.d) must be signed by a duly registered accountant; a copy of
registration certificate is to be appended to the application.
A. BANK DATA
Banker
Name of banker
Address of banker
Telephone:
Contact name and title:
Fax:
Telex:
Total Amount of Credit Line:
We hereby agree and authorize APMT-C to obtain confirmation of our financial data from our
banker as stated above.
Signature:
..................................................................................

Date:
.....................
Page 7/24
Insert

Financial Data
Form V.b
B. FINANCIAL INFORMATION
a.
Summarize actual assets and liabilities in USD equivalent (at the rates of exchange current at the
end of each year) for the previous three years on basis of the audited financial statement. A copy of
the audited balance sheet for each of the last three years shall be attached. All such financial
performance characteristics or documents shall reflect the financial situation of the Applicant or
member of an Applicant, and shall not include sister or parent companies.
b.
In case of an Applicant consisting of two or more firms, the financial information data shall
additionally be summarised in a separate sheet, being the sum of the individual values of each
member.
Financial Information
Previous three years [in Mio. USD]

2013
2014
2015
1. Total assets
2. Current assets
3. Total liabilities
4. Current liabilities
5. Profits before taxes
6. Profits after taxes
7. Net worth (= 1-3)
8. Working Capital (= 2-4)
9. Return on Equity (= 5 / 7 of prior year)
C . AN N U AL T U R N O V E R D
AT A
The information supplied should be the annual turnover of the Applicant (or each member of an Applicant,
respectively the specialized sub-contractor), in terms of the amounts billed to clients for each year for
work in progress or completed, converted to USD at the rate of exchange at the end of the period
reported. Moreover, in case of an Applicant consisting of two or more firms, the annual turnover data shall
be provided in a separate sheet, being the sum of the individual values of each member.
Annual turnover data for the last three years

Year
Total turnover [in Mio. USD]
Works contract turnover [in Mio. USD]
2013
2014
2015
Signature:
..................................................................................
(a duly registered accountant)

Date:
.....................
Page 8/24
Insert

Financial Data
Form V.c
D. LIST OF ONGOING CONTRACTS

List ongoing
categories:
contracts
according
to
following
(a) Design-Build contracts

(b) General marine works contracts
(c) Repair works in open-pile wharf structures
(d) Fire-fighting equipment
(e) Buildings refurbishment
(f)
Equipment (electrical, pressurized air and water supply systems)
refurbishment
In case of an Applicant of two or more firms, the list of ongoing contracts of all members shall be provided
in a separate sheet, being the sum of the individual values of each member. Only contracts reflecting the
contract situation of the Applicant, the member of an Applicant or the sub-contractor shall be listed, no
contracts of sister or parent companies shall be included.
Name and type of

contract
Contract value
[USD]
Name of
owner
Value of
remaining work
under current
contracts [USD]
Scheduled
completion
date
(a)
(b)
(c)
(d)
(e)
(f)
Total values
Signature:
..................................................................................

Date:
.....................
Page 9/24
Insert

Financial Data
Form V.d
E. BID GUARANTEE
Name/Address of proposed Surety by:
Ceiling Amount of Bid Guarantee:

US $
F. APPLICANT'S INSURER
1.
Name/Address of insurer(s)
2.
Ceiling Amount of Contractor's All Risk Insurance for a single project, evidenced by a
letter of confirmation of insurance company:
US $
Signature:
..................................................................................

Date:
.....................
Page 10/24
Insert

Technical Qualification
Form VI.a
A. ORGANISATION CHART / HOME OFFICE

Please give details here below of the organisation chart of your company, showing the position of directors,
key personnel and functions as relevant for this project. (Not necessary for sub-contractors)
Signature:
..................................................................................

Date:
.....................
Page 11/24
Insert

Form VI.b
B. ORGANISATION CHART / SITE MANAGEMENT

Please give details here below of the organisation chart of the site management, showing the position of
construction manager, key personnel and functions as considered appropriate for this project. (Not necessary for
sub-contractors)
Signature:
..................................................................................

Date:
.....................
Page 12/24
Insert

Form VI.c
C. INDUSTRY ACCREDITATIONS
Please list here below the industry accreditations appropriate for this project. (Not necessary for sub-contractors)
No.1
(a)
(b)
(c)
(d)
No.2
No.3
No.4
ISO Certificate No.s

Systems Assurances
Safety Accreditations
Other Accreditations
Signature:
..................................................................................

Date:
.....................
Page 13/24
Insert

Form VI.d
D. OVERVIEW OF TOTAL STAFF

(Total staff employed by applicant / applicants may add professionals if relevant)
a - Directors and management
........................
b - Administrative staff
- Contract specialists (FIDIC, Design-Build, etc.)..
- Accounting and controlling
........................
- Health and safety
..
- Quality Management
..
c - Technical staff
- Design engineers (marine structures)
- Design engineers (pile repair works)
- Design engineers (Firefighting system)
- Design engineers (building refurbishment)
- Geotechnical experts
- Pile driving experts
- Site engineers
- HSE engineers
- Mechanical/ Electrical engineers
- Concrete experts
Total
Signature:
..
..
..
..
........................
........................
........................
........................
........................
........................
===========
..................................................................................

Date:
.....................
Page 14/24
Insert

Form VI.e
E. OVERVIEW OF SITE PERSONNEL

(Site personnel to be employed for the project / Applicants may propose additional professionals if
relevant)
a - Site management
.......................
b - Administrative staff
- Contract specialists (FIDIC, Design-Build, etc.)..
- Health and safety
..
- Quality Management
..
c - Technical staff
- Design engineers (marine structures)
- Design engineers (pile repair works)
- Design engineers (Firefighting system)
- Design engineers (building refurbishment)
- Pile driving experts
- Site engineers
- HSE engineers
- Mechanical/ Electrical engineers
- Concrete experts
- Foremen
- Drivers/ operators
- Other skilled staff
- Labourers and unskilled staff
Total
Signature:
..
..
..
..
........................
........................
........................
........................
........................
..
........................
..
........................
===========
..................................................................................

Date:
.....................
Page 15/24
Insert

Form VI.f
F. CAPABILITIES OF KEY PERSONNEL

For specific positions, essential to contract management and implementation, Applicants shall provide the
names of at least two experts qualified to meet the specified requirements stated for each position. The
data on experience / curriculum vitae should be supplied for each expert on separate sheets using
the attached form.
1.
Title of position:
Construction manager
Work experience: 15 years of which 10 years of similar project experience
Contract values handled during past 5 years > USD 5 million per annum (evidence to be provided)
Name of prime candidate:
Name of alternative candidate:
2.
Title of position:
Deputy manager/ site engineer
3.
Title of position:
Chief design engineer (maritime structures)
4.
Title of position:
Contract specialist (FIDIC and Design-Build contracts)
5.
Title of position:
Mechanical/ electrical Engineer
6.
Title of position:
Concrete specialist/ quality control
Work experience: 10 years of similar project experience
Page 16/24
Insert
7.

Title of position:
Pile driving expert
8.
Title of position:
Quality management
9.
Title of position:
Health and safety expert
Work experience: 5 years of similar project experience
Surveyor
10. Title of position:
Signature:
..................................................................................

Date:
.....................
Page 17/24
Insert

Form VI.g
G. PROFESSIONAL EXPERIENCE OF KEY PERSONNEL - CURRICULUM VITAE

(Maximum 3 pages)
Proposed position in the contract:

Company name:
1.
Surname:
2.
Name:
3.
Date and place of birth:
4.
Nationality:
5.
Civil status:
6.
Address (phone/fax/e-mail):
7.
Education:
Institutions:
Date:
From (month/year)
To (month/year)
Degree:
8.
Language skills
(On a scale of 1 to 5, with 5 being the highest):
Language
Level
Passive
Mother tongue
9.
Membership of professional bodies:
10.
Other skills (e.g. computer literacy, etc.):
11.
12.
13.
Present position:
Years of professional experience:
Key qualifications:
14. Specific experience in non-industrialised countries:

Country
Date: from (month/year) to
(month/year)
Spoken
Written
Name and brief description of the

project
Page 18/24
Insert

15. Professional experience:

Date: from (month/year) to (month/year)
Place
Company/organisation
Position
Job description
16.
17.
18.
Date:
Others:
Publications and seminars:
References:
.....................
Signature of staff member:

Full name of staff member:
Signature of authorised representative of firm:..................................................

Full name of authorised representative:
Page 19/24
Insert

Form VI.h
H. PLANT AND EQUIPMENT

Plant and equipment, proposed and available for the performance of the project, i.e. piling repair
equipment, concrete repair and curing systems, driving equipment, etc.
No.
Description
Power/
(type/make/model) capacity
No. of
units
Age
Hired/
Origin
Owned
(operating
by
leased by (country)
hours) Applicant Applicant
Present
approximate
value in USD
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Signature:
..................................................................................

Date:
.....................
Page 20/24
Insert

Technical Experience
Form VII.a
A. EXPERIENCE IN DESIGN OF MARITIME STRUCTURES

The design of the refurbishment works for APMT-C may be carried out by the specialised design
department of the Applicant/ member of an Applicant or through hired sub-contractor(s) specialised in
design of marine works and repair of piling structures. The Applicant/ specialised sub-contractor(s) shall
list contracts of similar nature and of relevant extent performed during the past 10 years which best
illustrate his qualifications.
The Applicant/ specialised sub-contractor for design of the marine works has to submit evidence of listed
experience by brochures, references and certificates from the relevant Employers, Clients.
Name Client and Total value of

and
address
the
location
construction
of project
works [USD]
Signature:
Value of
design
services
[USD]
Planning period/
No. of staff-month/
duration of
assignment
Description of design services

and characteristics of relevant
marine structure components
..................................................................................

Date:
.....................
Page 21/24
Insert

Form VII.b
B. EXPERIENCE AS CONTRACTOR IN DESIGN-BUILD CONTRACTS

List contracts of Design-Build nature (Yellow Book FIDIC Contract) performed during the past 10 years
worldwide and specially in South America
Name of Total value of Period of Starting

project / kind works the
contract
date
of works
Contractor
was
responsible
for [USD]
Percentage Contracting
Prime
of works
authority and contractor
completed
place
(P) or
subcontract
or (S)
Final
acceptance
issued?
- Yes
- Not yet
(current
contracts)
No
Please attach hereto available references and certificates from the relevant Employers, Clients.
Signature:
..................................................................................

Date:
.....................
Page 22/24
Insert

Form VII.c
C. EXPERIENCE AS CONTRACTOR IN SIMILAR MARINE WORKS PROJECTS

List on separate sheets contracts of similar nature: a) marine concrete structures, b) repair of piled
structures, c) repair of concrete structures, d) berth equipment repair and new installation, e) dismantling
and deconstruction of old structures, etc.) and extent performed during the past 10 years

contract
date
of works
Contractor
was
responsible
for [USD]
Prime
of works
completed
place
(P)
or subcontractor
(S)
Final
acceptance
issued?
- Yes
- Not yet
(current
contracts)
No
Please attach here available references and certificates from the relevant Employers, Clients.
Signature:
..................................................................................

Date:
.....................
Page 23/24
Insert

Form VII.d
D. EXPERIENCE AS CONTRACTOR IN SIMILAR BUILDING WORKS, UTILITIES

AND EQUIPMENT REFURBISHMENT PROJECTS ETC.
List contracts of similar nature: a) civil works, b) electrical/ mechanical works, c) pressurized air system,
d) dismantling and deconstruction of old structures, etc. and extent performed during the past 10 years

contract
date
of works
Contractor
was
responsible
for [USD]
Prime
of works
completed
place
(P)
or subcontractor
(S)
Final
acceptance
issued?
- Yes
- Not yet
(current
contracts)
No
Signature:
..................................................................................

Date:
.....................
Page 24/24
Insert

Form VII.e
E. EXPERIENCE AS CONTRACTOR IN SIMILAR FIRE FIGHTING EQUIPMENT

WORKS
List contracts of similar firefighting system, such as implementation works in oil piers, and extent / type of
works performed during the past 10 years

contract
date
of works
Contractor
was
responsible
for [USD]
Prime
of works
completed
place
(P)
or subcontractor
(S)
Final
acceptance
issued?
- Yes
- Not yet
(current
contracts)
No
Signature:
..................................................................................

Date:
.....................
Page 25/24
Insert

Form VII.f
F. CURRENT AND HISTORICAL PROJECT DATA. SCOPE SPECIFIC DATA

List contracts of similar firefighting system, such as implementation works in oil piers, and extent / type of
works performed during the past 5 years
(a)
No. and value of projects currently being undertaken as per scope preference(s)
indicated in Form VII above:
Approx.
Approx.
No.
US$000s
No.
US$000s
Home Region
Globally
Latin America
Colombia
(b)
No. and value of projects completed as per scope preference(s) (last 10 years) indicated
in Form VII above:
Approx.
Approx.
No.
US$000s
No.
US$000s
Home Region
Globally
Latin America
Colombia
(c)
(d)
No. of live/brown field port facilities projects:

Home Region
Globally
No. of green field port facilities projects:

Home Region
Globally
Signature:
..................................................................................

Date:
.....................
Page 26/24
Insert

Safety Record
Form VIII
Please provide information on safety history resulting from contracts indicated in Form VII above
executed during the last 10 years or currently under execution.
Company is to indicate its safety record below:

Home
Region
(a)
i
ii
iii
iv
v
Globally
On projects current/completed as shown in Form VII.f

Total No. of man hours worked
Total No. of incidents
Total No. of Loss Time Accidents (LTA)
Total No. of fatalities
Total No. of hours since last LTA
Signature:
..................................................................................

Date:
.....................
Page 27/24
Insert
Litigation History

Form IX
Please provide information on any history of litigation or arbitration resulting from contracts executed
during the last 10 years or currently under execution.
A separate sheet should be used for each member of an Applicant consisting of two or more firms as well
as specialized sub-contractors (with a work contents in excess of 15% of the value of the whole works).
Year
Award FOR
or AGAINST
tenderer
Signature:
Name of client, cause of litigation, and

matter in dispute
Disputed amount
(current value in USD)
Pending (P) /
Settled (S)
..................................................................................
Date:
.....................
Page 28/24

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Annex 2

FORMS FOR PREQUALIFICATION

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

Refurbishment of the marine works-Piers.

APM Terminals Callao S.A.

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

We hereby apply to be qualified as a bidder for the APMT-C Project.

We authorize the APMT-C or its authorized representatives to conduct any

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

Signed on behalf of the Applicant

(a person or persons authorised to sign on behalf of the Applicant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

Head office address:

Address of local office or agency (if any):

Main lines of business

(a person or persons authorised to sign on behalf of the Applicant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

Data of Applicants consisting of two firms

Managing board's address..................................................

Name of lead partner

Agreement governing the formation of the Applicant consisting of two

(a person or persons authorised to sign on behalf of the Applicant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

Section of work in this

Detailed design of firefighting

Detailed design of electrical

(a person or persons authorised to sign on behalf of the Applicant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

Contact name and title:

Total Amount of Credit Line:

(a person or persons authorised to sign on behalf of the Applicant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

Previous three years [in Mio. USD]

Annual turnover data for the last three years

Total turnover [in Mio. USD]

Works contract turnover [in Mio. USD]

(a duly registered accountant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

D. LIST OF ONGOING CONTRACTS

(a) Design-Build contracts

Name and type of

(a duly registered accountant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

Ceiling Amount of Bid Guarantee:

(a duly registered accountant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

A. ORGANISATION CHART / HOME OFFICE

(a person or persons authorised to sign on behalf of the Applicant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

B. ORGANISATION CHART / SITE MANAGEMENT

(a person or persons authorised to sign on behalf of the Applicant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

ISO Certificate No.s

(a person or persons authorised to sign on behalf of the Applicant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

D. OVERVIEW OF TOTAL STAFF

a - Directors and management

(a person or persons authorised to sign on behalf of the Applicant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

E. OVERVIEW OF SITE PERSONNEL

(a person or persons authorised to sign on behalf of the Applicant)

PRE-QUALIFICATION DOCUMENT FOR DESIGN BUILD CONTRACT

F. CAPABILITIES OF KEY PERSONNEL