Annex II

FORM FOR SUBMITTING SERVICE PROVIDERS PROPOSAL1

(This Form must be submitted only using the Service Providers Official Letterhead/Stationery2)

[insert: Location].
[insert: Date]

To: Ms. Negar Arefi

Head of Operations (GFATM Grants)

Dear Sir/Madam:
We, the undersigned, hereby offer to render the following services to UNDP in conformity
with the requirements defined in the RFP dated July 09, 2013, and all of its attachments, as well as
the provisions of the UNDP General Contract Terms and Conditions:

A. Qualifications of the Service Provider

The Service Provider must describe and explain how and why they are the best entity that can
deliver the requirements of UNDP by indicating the following:

Item A-a: Profile please describe the nature of business, field of expertise, procedure of
decision making;
Item A-b: Business Licenses- please complete item A-b bellow and please submit the
Registration Papers, Official Gazette, Tax Payment Certification, etc;
Item A-c: Latest Audited Financial Statement please attach the income statement and
balance sheet to indicate your financial stability, liquidity, credit standing, and market
reputation, etc, and please list the attached documents in the following Item A-c;
Item A-d: Track Record- list of clients for similar services as those required by UNDP,
indicating description of contract scope, contract duration, contract value, contact references.
Please use Item A-d as a guide to provide the requested information;
Item A-e: Certificates and Accreditation please attach Quality Certificates, Patent
Registrations, Environmental Sustainability Certificates, etc. and list the attached documents
in following Item A-e;
Item A-f: Written Self-Declaration please note that by completing the following Item A-f,
you declare that your company is not in the UN Security Council 1267/1989 List, UN
Procurement Division List or Other UN Ineligibility List.

Item A-a

Profile of the Firm/Organization

Full name of organization (in Farsi):
Full name of organization (in English):
Central office address:
Tel No:

1This serves as a guide to the Service Provider in preparing the Proposal.

2
Official Letterhead/Stationery must indicate contact details addresses, email, phone and fax numbers for
verification purposes.

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 1 of 11
 Fax No:
E-mail:
Website:
Nature of business, field of expertise:
Summary of Goals and Mission of Organization:

Name of General Manager (please attached the C.V. of General Manager):

Name of Chair of Board of Directors/Trustees:

Number of the member of Board of Directors/Trustees:

Number of employees (excluding Board of Directors/Trustees):

Structure of the organization, number of staff including all administrative bodies, core
areas of expertise and experience

Procedure of decision making, in particular financial decisions.

Brief explanation of how the firm/organization secures the quality and accuracy of such
decisions:

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 2 of 11
Item A-b

Legal and Registration Information:

Organizations year of establishment ) ( :
Organizations official registration date ) ( :

Please specify under which of the following modalities/organizations the entity is registered:
Ministry of Interior Office as a Non- governmental/non- profit organization (
)
Youth national organization ) ( :
Office of registration of companies and industrial ownership (
)
Others: ..

Registered under name of:

Number and date of registration on permission of activity ) ( :

Please explain if your firm/organization has any history or experience of disagreement leading
to taking any contractual case to law court. If yes, please describe the case.

Item A-c

Latest Audited Financial Statement: Please list the required documents you have attached to
indicate your financial stability, liquidity credit, standing and market reputation, etc.

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 3 of 11
Item A-d

Track Record and Experiences: Provide the following information regarding corporate
experience within the last five (5) years which are related or relevant to those required for this
Contract:

Name of Client Contract Period Contracts References Contact Details

project Value of scope (Name, Phone, Email)
activity

Item A-e

Certificates and Accreditation: Please list the document which you have attached to your
proposal as requested in Section A, Item e.

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 4 of 11
Item A-f

Written Self- Declaration

Hereby I declare that my company is not in the UN Security Council 1267/1989 List, UN
Procurement Division List or Other UN Ineligibility List.

(Please note that by completing and signing this proposal you declare and confirm that your
company is not in the UN Security Council 1267/1989 List, UN Procurement Division List or
Other UN Ineligibility List.)

B. Proposed Methodology for the Completion of Services

The Service Provider must describe how it will address/deliver the demands of the RFP; providing
a detailed description of the essential performance characteristics, reporting conditions and
quality assurance mechanisms that will be put in place, while demonstrating that the proposed
methodology will be appropriate to the local conditions and context of the work.
(please fill Item B)

Item B

Proposed Methodology for the Completion of Services

Please explain your understanding of the objectives of this work, expected outputs and how your
firm/organization could contribute to achievement of the outputs:

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 5 of 11
Please explain your methodology and approach for carrying out the activities and obtaining the
expected outputs. In this section please explain if your firm/organization intends to sub-contract
part of the work. If yes, please describe in detail, name the potential sub-contractor(s) and provide
sufficient information on their profile.

Please explain your understanding of the expected challenges and problems in implementation of
this work and explain your approach to address and resolve them.

Please develop an action plan with steps and timeframe for activities to be conducted by your
organization including coordination with other organizations required for implementation of the
work.

Example:

Steps Involved entities Timeframe Responsible entity/individual

(if applicable) (if applicable)

Please explain in details your monitoring and evaluation system for quality assurance of the
provided services.

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 6 of 11
C. Qualifications of Key Personnel

Please provide:

a) Names and qualifications of the key personnel that will perform the services indicating who
is Team Leader, who are supporting, etc.;
b) CVs of the key personnel that will perform the services which demonstrates qualifications;
and
c) Written confirmation from each personnel that they are available for the entire duration of
the contract.

Item C-a

CV of Individuals with Health, preferably epidemiology background to be assigned as Head

of Team for the work of this contract (for minimum requirements please see TOR)
1. Name of Firm/Organization:
2. Full Name of individual:
3. Date of Birth: 4. Nationality:
5. Education:

6. Membership of Professional Associations:

7. Other Training:

8. Countries of Work Experience:

9. English Proficiency [Please indicate proficiency: good, fair, or poor in speaking, reading,
and writing]:

10. Employment Record [Starting with present position, list in reverse order every employment
held by individual since graduation, giving for each employment (see format here below):
dates of employment, name of employing organization, positions held.]:
From year To year Employer Position Activities performed

11. Other relevant information:

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 7 of 11
Given the high level of administration and financial work involved in this contract, you
are recommended to provide the list of key personnel in these areas and provide their
information (CV) below. Please use as many forms as needed.

CV of Key Personnel to be assigned for the work of this contract

1. Name of Firm/Organization:
2. Full Name of individual:
3. Date of Birth: 4. Nationality:
5. Education:

6. Membership of Professional Associations:

7. Other Training:

8. Countries of Work Experience:

9. English Proficiency [Please indicate proficiency: good, fair, or poor in speaking, reading, and
writing]:

10. Employment Record [Starting with present position, list in reverse order every employment
held by individual since graduation, giving for each employment (see format here below):
dates of employment, name of employing organization, positions held.]:

From To year Employer Position Activities performed

year

11. Other relevant information:

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 8 of 11
D. Cost Breakdown by Cost Component:

Item D-a (Research Proposal and Operational Protocol/Guideline)

Description of Activity Unit cost (A) Quantity (B) Total Rate

(Ax B) IRR
1. Personnel Services
2. Developing the required survey
protocols and questionnaires
3. Providing copy of protocol 50
4. Providing copy of questionnaire 1500
Total

Item D-b (Organizing One Instructive One-day Workshop)

Description of Activity/Item Unit cost Quantity Total Rate
IRR(A) (B) (Ax B) IRR
1. Workshop Venue and facilities (Venue, AV,
Audio- Visual and IT equipment, etc.) for 110 - -
participants
2. Refreshment (tea, coffee, fruit and pastry) for 2 (Morning
110 participants and
Afternoon)
3. Lunch:
Including two different main courses and side 1 Lunch
dishes (Yoghurt, salad, drinks) for 110
participants
Extra lunch including two different main courses 1 Lunch
and side dishes (Yoghurt, salad, drinks) for 48
participants in case of flight limitation
4. Accommodation
In Tehran (room and breakfast) one night for 96 1 Night
participants
One additional night for 48 participants in case of 1 Night
flight limitation
5. Transportation
Air /other transportation ticket from cities to 96
Tehran considering the distance and availability Participants
of airport as per the attachments A to Annex IV
Taxi cost of participants from Airport/land 96
terminal to workshop venue and vise versa Participants
6. Dinner
Including two different main courses and side
1 Dinner
dishes (Yoghurt, salad, drinks) for 96 participants
Extra dinner including two different main courses
and side dishes (Yoghurt, salad, drinks) for 48 1 Dinner
participants in case of flight limitation
7. Providing handouts, CDs, stationery, etc. - -
8. Any other relevant cost item required for
arrangement of a workshop such as
- -
(communication, reporting, printings and other
miscellaneous costs)
9. IT Assistant for support during workshop 1 Day

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 9 of 11
 ........................
10. Cost of holding one 1-day workshop (item 1 [ Total cost of
-
to 9) one 1-day
workshop]
........................
11. Administration fee (to be proposed by [ ...%] [Percentage of
Offeror as a percentage over the incurred cost) Admin Fee x
Item 10]
........................
Total for One 1-day workshop [Item 10 + Item
11]

Item D-c (Conducting Survey)

Please consult with national price reference to fill out the section

Description of Activity Unit cost (A) Quantity (B) Total Rate

(Ax B) IRR
1. Sampling tests including specialist 1000
physical exam, CXR with radiologist (Individual)
report and PPD
2. Sputum smear and culture 100
(Individual)
3. DST for all detected TB cases 20
(Individual)
4. Cost of transportation of samples to ------
the designated lab in the country

5. Conducting interview and completion 1000

of questionnaires for the sample (Individual)
population (all the related costs
including transportation to designated
sites, accommodation , etc. should be
considered)

6. Conducting a second interview to 100

validate 10% of questionnaires of (Individual)
study population (all the related costs
including transportation to designated
sites, accommodation , etc. should be
considered)

Total

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 10 of 11
E. Cost Breakdown per Deliverable

Row Deliverables Percentage of Total Price Price

(Weight for payment) (Lump Sum,
All
Inclusive)
1 Developing research proposal and
operational protocol/guideline (should
read from table D-a)
2 Organizing one instructive one-day
workshop (should read from table D-b)
3 Conducting survey (should read from
table D-c)
4 Submission of progress report and final
report with thorough analysis as
explained in Annex IV.
Total 100%
*This shall be the basis of the payment tranches

[Name and Signature of the Service Providers

Authorized Person]
[Designation]
[Date]

No. 8, Shahrzad Blvd, Darrous, 1948773911 Tehran, I.R. Iran (P.O. Box 15875-4557)
Tel: (98 21) 2286 0691-4, 286 0925-8, Fax: (98 21) 22869547, Email: registry@undp.org, website:
www.undp.org.ir
Page 11 of 11