Web Site

							                                                                                                   P. 1




                                                     Supplier Registration Form


This form should be completed in FULL and must be returned by registered mail to :–

      Hospital Authority,
      Procurement and Materials Management Section
      147B, Argyle Street,
      Kowloon, Hong Kong.
                                      PART I — DETAILS OF THE COMPANY ——
 1.   Name of Company:

 2.   Address(es):                                                                    Tel. No.:

      (1)    Office:                                                                  Fax No.:

      (2)    Factory / Warehouse (if applicable) :                                    E-Mail :

                                                                                      Web Site :
 3.   Nature of business:

 4.   How long in present business:

                                 PART II — ORGANIZATIONS AND STAFF ——
 1.   Members of organization holding executive functions :


                                               Name

      (1)    *Managing director:

      (2)    *Directors:

      (3)    *Owners/Proprietors:

      (4)    Partners:


 2.   Number of persons employed:


      (1)    Managerial staff:


      (2)    Clerical staff:


      (3)    Technical staff:


      (4)    Workers/Other staff:


* (Delete where inappropriate)
Form PMMS-005/2011-09       Rev 7
                                                                                                                           P. 2



 3.   Persons to contact on matters relating to tenders/contracts:


              Name(s)                      Official Capacity                    Tel. No.              Fax No.   E-Mail




                            PART III — BUSINESS ACTIVITIES AND DOCUMENTS ——

 1.   Goods and services which your company can supply/provide:


      (i)     Detailed list of goods and services




      (ii)    Please provide the name(s) of the principal(s) for whom you act as the accredited agent(s)/distributor(s)in case
              you are not the manufacturer. (Please enclose a copy of proof of appointment of sole agent/distributor)




      (iii)   Please enclose one set of relevant catalogues and descriptive literature for consideration.




                                            (Note : If space is not sufficient, please use separate sheet)



Form PMMS-005/2011-09     Rev 7
                                                                                                                         P. 3




 2.   (i)    Please submit the following documents for reference and record:




             (a)   A copy of a valid Business Registration Certificate.


             (b)   Memorandum and Articles of Association (for body corporate only e.g. limited company).


             (c)   Company profile and annual report.




      (ii)   The names and addresses of firms (preferably six numbers ) to whom you have supplied goods/services and who
             would be prepared to provide, if required, references in respect of the orders/service contracts which you have
             undertaken with them.




                                 Name and Address                                     Goods/services supplied




                                         (Note : If space is not sufficient, please use separate sheet)



Form PMMS-005/2011-09   Rev 7
                                                                                                                        P. 4



                                           PART IV — CERTIFICATION ——

I apply on behalf of the Company to register as a Hospital Authority supplier.




                                                  Signature:___________________________________________________


                                                  Name in block letters:_________________________________________


                                                  Designation:_________________________________________________


               (Space for company chop)           Date:_______________________________________________________




                                           NOTES FOR GUIDANCE
Purpo se o f Co llect io n
       T he p erso nal d ata p r o vid ed b y means o f this fo rm will b e used b y the Ho sp ital Autho rity fo r
co nsid eratio n o n the ap p licat io n fo r sup p lier registratio n fo r tend er invitatio n.

Tra nsfer o f Da ta
       T he p erso nal d ata yo u p r o vid e b y means o f this fo rm may b e d isclo sed to o ther p ub lic ho sp itals.

Access o f Perso na l Da t a
       Yo u have the r ight o f access and co rrectio n with resp ect to p e rso nal d ata as p ro vid ed fo r in
sectio n 1 8 and 2 2 P r incip le 6 o f Sched ule 1 o f the P erso nal Data (P rivacy) Ord inance. Yo ur right o f
access includ es the r ight to o b tain a co p y o f yo ur p erso nal d ata p ro vid ed b y this fo rm.


Enquiries
       Enq uiries co ncer ning the p er so nal d ata co llected b y means o f this fo rm, includ ing the making o f
access and co rrectio ns, sho uld b e ad d r essed to :
       Senio r Sup p lies Officer ( P T A)
       P ro curement and Mater ials Management Sectio n
       Rm 3 1 0 N, 3 /F Ho sp ital Autho r ity B uild ing
       1 4 7 B Argyle Str eet Ko wlo o n
       T el : (8 5 2 ) 2 3 0 0 7 4 6 5
       Fax : (8 5 2 ) 2 5 1 5 9 0 4 6
       E-mail : p mms@ha.o r g.hk




Form PMMS-005/2011-09      Rev 7