VÁPENKA VITOŠOV s.r.o.

PREQUALIFICATION QUESTIONNAIRE

PREQUALIFICATION SAFETY QUESTIONNAIRE FOR SUPPLIERS

1. About company

* Company name

* Address

* Number of employees

2. Company representative

* First name

* Surname

* Telephone number

* E-mail address

3. Reponsible person for safety

* First name

* Surname

* Job Title

* Telephone number

* E-mail address

4. Activities

* Please choose the activities you would like to perform:

Previous experience in performing these activities (references):

5. Documentation

* Which of the following documents do you have available? (the documents must be submit to the Client without delay at the Client´s request)

6. Safety Management

* Information related to Safety Management System in your company. (mark to confirm validity)

7. Accidents

* Do you have a procedure for reporting employee injuries and accidents?

* Please write down the number of employee injuries you have recorded in your company in the last 5 years (fatal accidents, lost time injuries)

* Have the authorities been imposing a fine for your company for breaching health, safety and environment regulations in the last 5 years? (please provide details)

8. Contact (responsible) person from VÁPENKA VITOŠOV s.r.o.

* First name

* Surname

9. Notes

Here you have opportunity to make any comments related with prequalification process:

10. Statement by the person completing this form

* I hereby certify that the above information given in the prequalification questionnaire are true and correct. I am committed to notify any changing work procedure, changing personnel or equipment.

* First name

* Surname

* E-mail address

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