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Page 12 of 17 SECTION – B FORM – I PRE-QUALIFICATION APPLICATION To The Chairman Jangipur Municipality P.O & P.S – Raghunathganj Dist – Murshidabad, W.B Ref : Tender for................................................................................................... (Name of work).................................................................................................. ................................................................................................................................................... NIeT No: MAD/ULB/JM/MSDP/NIeT1/19-20 (1st Call), Vide Memo No - 1971/e-Tender/112/19/JM Date – 09/08/2019 of the Jangipur Municipality, P.O & P.S – Raghunathganj Dist – Murshidabad, W.B Dear Sir, Having examined the Statutory, Non-statutory & N.I.T. documents, I /we hereby submit all the necessary information and relevant documents for evaluation. The application is made by me / us on behalf of...................................................................... ......................................................................................................................................in the Capacity ..................................................................................................................... duly authorized to submit the order. The necessary evidence admissible by law in respect of authority assigned to us on behalf of the group of firms for Application and for completion of the contract documents is attached herewith. We are interested in bidding for the work(s) given in Enclosure to this letter. We understand that: i) Tender Inviting Authority can amend the scope & value of the contract bid under this project. ii) Tender Inviting Authority reserves the right to reject any application without assigning any reason. Enclosure(s): e-Filing:- iii) Statutory Documents. iv) Non Statutory Documents. Financial proposal v). Bill of quantities (BOQ). (With quoted the rate) Date:................................... .................................................................................. Signature of applicant including title and capacity in which application is made. Page 13 of 17 SECTION – B AFFIDAVIT – “Y” (To be furnished in Non – Judicial Stamp paper of appropriate value duly notarized) vi) I, the under-signed do certify that all the statements made in the attached documents are true and correct. In case of any information submitted proved to be false or concealed, the application may be rejected and no objection/claim will be raised by the under-signed. vii) The under-signed also hereby certifies that neither our firm M/S......................................... ..................................................nor any of constituent partner had been Barred/ Delisted/ Black listed to participate in tender by the Govt./Undertakings during the last 5 (five) years prior to the date of this N.I.T. Viii) The under-signed would authorize and request any Bank, person, Firm or Corporation to furnish pertinent information as deemed necessary and/or as requested by the Corporation to verify this statement. ix) The under-signed understands that further qualifying information may be requested and agrees to furnish any such information at the request of the Corporation. x) Certified that I have applied in the tender in the capacity of individual/ as a partner of a firm and I have not applied severally for the same job. ................................................................

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