Fish Product Board
Fish Product Board
Own Declaration pertaining to a public procedure
( blue fields by the Tenderer or candidate)
Own Declaration
in respect of exclusion and suitability criteria
pertaining to specifications <<47/AH/SM Juvenile eel>>
Juvenile eel purchase 2012
Place of implementation:
Designated locations in the Netherlands (to be determined)
Type of order:
Supply
Tendering procedure:
European tender in accordance with the public procedure
Contracting Authority:
Fish Product Board in Rijswijk
Date and time of tender:
22-02-2012 at 12.00
This completed and signed Own Declaration, with the required numbered Annexes, must be added to
the other tender documents and must be submitted to the following address as a single copy by the
deadline for receiving the tenders:
Address:
Name:
Fish Product Board
F.a.o.:
A. Heinen,
Address:
Treubstraat 17,
Town:
Rijswijk
Postal address:
Name:
Fish Product Board
F.a.o.:
A. Heinen,
Address:
Postbus 72,
Town:
2280 AB Rijswijk
Assessing the suitability of the tenderer will find place according the criteria stated in the
Announcement of an order of 11th of January 2012.
Fish Product Board
Instructions for completing and submitting this Own Declaration
This Own Declaration (the original) must be completed in full. If you tender in combination with others, each
consortium member must submit a completed copy of this Declaration. A copy of this Own Declaration may be
used for that purpose.
The text of this Own Declaration may not be typed over, supplemented or amended. If the Own Declaration does
not have enough room for answers, please note those on separate Annexes. Where this is indicated on this Own
Declaration, separate Annexes must be added. If it says ‘following such a request’, you only need to submit the
relevant details after the Contracting Authority has sent you a written request to that effect. Such a submission
must take place within the (reasonable) term included in the request. Annexes must be given the question number
from this Own Declaration.
If you tender making use of subcontractors (question 1 sub i), every subcontractor must complete questions 1, 2
and 3 in this Own Declaration, sign it and submit it together with this Own Declaration. In the case of
subcontracting, making use of a copy of questions 1, 2 and 3 of this Own Declaration is permitted where
necessary.
The completed Own Declaration, including the numbered Annexes, must be received as part of the tender at the
deadline for receiving tenders at the postal address included in the notice. If the Own Declaration is enclosed in a
separate
envelope,
it
must
state
clearly
that
this
pertains
to
this
procedure.
You bear the risk for the proper and timely arrival of the Own Declaration.
Questions or Comments
Questions following the activities to be carried out, the Own Declaration and any regulations that are referred to,
etc may be submitted in the manner described in Section VI.3 of the notice.
If you have more general questions or comments about the tendering policy of the Contracting Authority, or if you
believe that you are or have been treated incorrectly in any tendering procedure of the Contracting Authority, or if
your questions have not been answered properly, please contact the Contracting Authority referred to in Section
I.1 of the notice.
Juvenile eel purchase 2012
Own Declaration Public Procedure
Version no 02-2006
page 1
Fish Product Board
1
General questions
Question
Answer
Name of the business
name
Business address:
address, postcode and town
Postal address:
PO box number
Postcode and town:
postcode town
Country:
country of official address
Telephone number:
number
Fax number:
number
VAT registration
number
Name of the representative who is authorised to
complete the form on behalf of the business:
name
Business address:
address, postcode and town
Postal address:
PO Box number
Postcode and town:
postcode town
Country:
country of official address
Telephone number:
number
Fax number:
number
c.
Legal form of the business:
BV / CV/ NV / VOF / other
d.
The trade name or trade names the business uses or
has used:
name
e.
Registration number with the Register of Companies
or a comparable registration in the country of the
official address:
number; place of registration
Are there natural persons or legal entities who,
insofar as applicable, manage or have managed the
business directly or indirectly:
yes / no
Are there natural persons or legal entities who,
insofar as applicable, control or have controlled the
business directly or indirectly:
yes / no
Are there natural persons or legal entities who
provide or have provided equity to the company
directly or indirectly:
yes / no
If applicable, to which businesses will part of the
order be subcontracted, insofar as the value of that
part of the order is equal to or higher than the
threshold value that applies to the activities
yes / no
j.
Please state how this business is financed:
Method of financing
k.
Person who is duly authorised to take decisions on
behalf of the business in relation to this order:
name and initials
Business address:
address, postcode and town
Postal address:
PO Box number
Postcode and town:
postcode town
Contact person for the business:
name and initials
Telephone number:
number
E-mail address contact person:
e-mail address
a.
b.
f.
g.
h.
i.
l.
Juvenile eel purchase 2012
Submit following a request:
A copy of the proof of registration.
If yes, please list:
name, address, postcode and town
If yes, please list:
name, address, postcode and town
If yes, please list:
name, address, postcode and town
If yes, please list:
name natural person or legal entity, address, postcode and
town
Own Declaration Public Procedure
Version no 02-2006
page 2
Fish Product Board
2.
Exclusion criteria
The declarations required under question 2 may not be older than 6 months at the time of submission. The
business guarantees that this declaration matches the actual situation of the business at the time of submission.
Question
2.0
Answer
Annex
Exclusion criteria regarding participating in a criminal organisation, bribery, fraud or money laundering
Has a final judgement1 been pronounced against the
business for one or more of the following reasons:
-
-
Membership of a criminal organisation in the sense of
Article 2.1 of Joint Action 98/773/JBZ of the Council?
Bribery in the sense of Article 3 of the decision of the
Council of 26 May 1997, or Article 3.1 of Joint Action
98/742/JBZ of the Council, respectively?
Fraud in the sense of Article 1 of the agreement regarding
the protection of financial interests of the Community?
Money laundering in the sense of Article 1 of Directive no
91/308/EEC of the Council of 10 June 1991 to prevent the
use of the financial system for money laundering?
yes / no
yes / no
yes / no
yes / no
If yes, please state the offence, the penalty or
measure imposed and what the business did
to prevent a reoccurrence.
Submit following a request:
A Certificate of Good Behaviour for the
business or a decision in which the issue of
that Certificate is refused or a similar
declaration or decision from the country of
origin that is not older than 6 months.
2.1
Exclusion criteria that could provide cause for exclusion
a.
Is the business in a state of bankruptcy or being wound up,
or has the business suspended its activities, or is it subject
to a moratorium or payments or an arrangement with its
creditors, or is the business in a similar position by virtue of
a similar procedure in the legislation or regulations that are
applicable to it?
yes / no
If yes, please note the relevant situation
Submit following a request:
A declaration from the clerk of the Court or a
similar declaration from the country of origin
that is not older than 6 months.
b.
Has bankruptcy or the liquidation of the business been
petitioned or are there pending proceedings for a
moratorium on payments or an arrangement with creditors
or other similar procedures that occur in the legislation or
regulations applicable to it?
yes / no
If yes, please note the relevant situation
Submit following a request:
A declaration from the clerk of the Court or a
similar declaration from the country of origin
that is not older than 6 months.
c.
Has a court judgement, no longer open to appeal, been
given against the business in accordance with legislation or
regulations applicable to it, which ascertained an offence
concerning professional conduct?
yes / no
If yes, please state the offence, the penalty or
measure imposed and what the business did
to prevent a reoccurrence.
Submit following a request:
A Certificate of good Behaviour for the
business or the decision in which the issue of
that Certificate is refused or a similar
declaration or decision from the country of
origin that is not older than 6 months.
d.
Has the business been guilty of grave professional
misconduct?
yes / no
If yes, please state the offence, the penalty or
measure imposed and what the business did
to prevent a reoccurrence.
e.
Has the business fulfilled its obligations regarding payment
of social-security contributions in accordance with the
statutory provisions of its country of domicile or the
Netherlands?
yes / no
If no, please note any pending payment
obligations
Submit following a request:
A declaration from the tax receiver under
whom the tenderer resorts or a similar
declaration from the country of origin that is
not older than 6 months.
1
For the Netherlands: A conviction pronounced on the basis of Section 140, 177, 177a, 178, 225, 226, 227,
227a, 227b or 323a, 328ter, second subsection, 416, 417, 417bis, 420bis, 420ter or 420quater of the Criminal
Code.
Juvenile eel purchase 2012
Own Declaration Public Procedure
Version no 02-2006
page 3
Fish Product Board
Question
Answer
f.
Has the business fulfilled its obligations regarding payment
of taxes in accordance with the statutory provisions of its
country of domicile or the Netherlands?
yes / no
If no, please state any pending payment
obligations
Submit following a request:
A declaration from the tax receiver under
whom the tenderer resorts or a similar
declaration from the country of origin that is
not older than 6 months.
g.
Has the business been guilty to a serious degree of making
false statements in the provision of information that may be
required by virtue of tendering procedures or did the
business not provide that information?
yes / no
If yes, please state the offence, the penalty or
measure imposed and what the business did
to prevent a reoccurrence.
3.
Financial and economic capacity
You are requested to provide information as per the end of the last financial year. If major changes have occured
since the end of the financial year, you must note those too.
Question
Answer
a.
Please state the last closed financial year of the business

Technical and organisational criteria
Question

Annex
<<year>>
Answer
Are you able to submit a list of references for 3 projects
that demonstrate that your business has undertaken
projects of a similar quantity or scope during the last 3
years and completed them in time?
Annex
yes / no
Minimum requirement for this order:
Proven experience in supplying juvenile eels in good
condition. For new facilities, One recommendation from a
member of the WGEEL of the ICES/EIFAC.
Annex
Add overview as an Annex.
Provide a list of references in accordance
with the model from Annex 1 to this Own
Declaration.
Submit following a request:
Project documentation.
Has your facility been accredited by the Sustainable Eel
Group?
Juvenile eel purchase 2012
Own Declaration Public Procedure
Version no 02-2006
page 4
Fish Product Board
Signing the Own Declaration
The undersigned declares that all questions and Annexes have been answered fully and
truthfully and that the information provided in this questionnaire matches the reality and is
accurate and complete.
The Undersigned is aware of and agrees that the Contracting Authority may verify or have
verified the Own Declaration and the submitted proof and Appendices by the Public
Administration Probity Screening Agency (hereinafter referred to as Bureau BIBOB). If the
Contracting Authority wishes to proceed with verification of the data, the Undersigned shall
grant his cooperation. The Undersigned shall also grant his cooperation to an investigation
into the ‘origin of means’ to be carried out by the Contracting Authority or by Bureau BIBOB
on its behalf.
Thus truthfully completed on
day month year
in town
by, name and initials, position
duly representing business
Signature:
Juvenile eel purchase 2012
Own Declaration Public Procedure
Version no 02-2006
page 5
Fish Product Board
Annex 1
Model for stating a reference project for the benefit of Juvenile eel purchase
2012
Name project:
project name
Description of activities:
description
Time and place of implementation:
Period: description
Place of implementation: geographic
designation
Size of the project (construction costs):
€ amount (excl. VAT)
Name of client:
name,
address,
town,
telephone number.
Project carried out as lead contractor:
yes / no
The actual activities carried out by your
business in a consortium:
description of the activities, the percentage
and the name of the consortium members
Supplementary documentation/information:
yes / no
Description of nature and number:
description and number
Juvenile eel purchase 2012
Own Declaration Public Procedure
Version no 02-2006
page 6
Fish Product Board
Director’s declaration regarding lawfulness of tendering for Juvenile eel
purchase 2012
The undersigned declares that this tender was not created under the influence of an agreement,
decision or behaviour in breach of Dutch or European competition law.
Thus truthfully completed on day month year in town
by, name and initials,
as Director of position
who
duly represents in the matter of this tender.
Signature:
Complete and sign this ‘Director’s declaration on lawfulness of tender’ and add it to the tender form.
The tenderer bears the risk of presence of this declaration with the tender form.
Juvenile eel purchase 2012
Own Declaration Public Procedure
Version no 02-2006
page 7