Sample Declaration of Residency - Husky Energy

|PREQUALIFICATION QUESTIONNAIRE |
| |
|HUSKY Ref. No.:|8.34.1.081 |Services Title: |White Rose Extension Project |
| | | |(WREP) - Wellhead Platform |
| | | |(WHP) -Topsides Fabrication |
| | | |and Construction |
| |
| |THIS QUESTIONNAIRE IS TO BE COMPLETED BY VENDORS WHO ARE | |
| |INTERESTED IN SUPPLYING EQUIPMENT, MATERIALS AND/OR | |
| |SERVICES TO HUSKY OIL OPERATIONS LIMITED. THE | |
| |INFORMATION PROVIDED IS STRICTLY CONFIDENTIAL AND SOLELY | |
| |FOR THE USE OF HUSKY. | |
| |
|COMPLETED QUESTIONNAIRE MUST BE MAILED OR COURIERED TO: |
| |Husky Energy, East Coast Operations | |
| |Suite 901, Scotia Centre | |
| |235 Water Street | |
| |St. John's, NL A1C 1B6 | |
| |Attention: Mark Collett, Procurement Manager | |
|Company | | |
| |
| | |The signatory of this Questionnaire guarantees the trust| | |
| | |and accuracy of all responses given herein, and is an | | |
| | |authorized officer or agent of the company. | | |
| | |Information submitted and completed by: | | |
| | | | | |
| | |Name (Please Print) | | |
| | | | | |
| | |Title | | |
| | | | | |
| | |Signature | | |
| | | | | |
| | |Date | | |
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|To be completed by HUSKY: |
|Date | |Procurement | |
|Received: | |Signoff: | |
| | INDEX 1. Company Information 2. Subcontracting 3. Work History 4. Current Organizational Structure 5. Facilities & Infrastructure 6. Capabilities Statement 7. Contractor HSEQ Requirements 8. Canada-Newfoundland and Labrador Benefits Compliance 9. Technical Requirements 10. Attachments 11. Additional Comments
General Instructions HUSKY recognizes that we have many different types of contractors with
different core competencies and skill sets. In order to effectively assess
your Company / Consortium or Joint Venture, HUSKY requires that this
Questionnaire be filled out as it applies to your firm. HUSKY is committed to ensuring fairness in our Contractor selection
process. Prequalification will be based on your company meeting our
expectations for the services to be supplied. Submission Requirements In order to be considered, Contractors must submit two (2) copies of all
requested documentation in an envelope or package, which must be clearly
marked "REFERENCE NO. 8.34.1.081 - WHP Topsides Fabrication". Please provide one (1) original and one (1) copy of your formal response no
later than 2:00pm NST on 22 November 2013 to the address as shown below: Husky Energy Inc.
Suite 901, Scotia Centre
235 Water Street
St. John's, NL Canada
A1C 1B6 Attn: Mark Collett, Procurement Manager
Email: Mark.Collett@huskyenergy.com Any submission which is not received by 2:00 PM NDT 22 November 2013 will
be returned to sender, unopened, and will not be given any further
consideration as part of this procurement process. Contractors are required to submit their response to this Prequalification
Questionnaire in the following format and in the exact order as shown: Completed Pre-Qualification Questionnaire including;
1. Company / Consortium or Joint Venture Information
2. Subcontracting
3. Work History
4. Current Organizational Structure
5. Facilities and Infrastructure
6. Capabilities Statement
7. Contractor HSEQ Requirements
8. Canada - Newfoundland and Labrador Benefits Compliance
9. Technical Requirements
10 Attachments
11. Additional Comments
|1. Company / Consortium or Joint Venture Information | |1.1 |Company Name:| |
| |Street/Mailing Address of Office completing this Questionnaire |
| | |
| |City: | |Province: | |
| |Postal Code:| |
| |Country | |
| |Telephone: | |Fax: | |
| |Email | | | |
| |Address | | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| |Key Company Sales | |
| |Contact | |
| |Head Office |________________________________________________________|
| | |_____ |
| |Street / Mailing |________________________________________________________|
| |Address |_____ |
| |Canadian Head | |
| |Office: | |
| |Street/Mailing | |
| |Address: | |
| |Local Office: | |
| |Street/Mailing | |
| |Address: | | |1.2 |Type of Company / Consortium / Joint Venture |
| |Sole Proprietor | | |Partnership | | |
| |Corporation - | | |Corporation - | | |
| |Private | | |Public | | |
| |Other (please | |
| |identify): | | Please supply Certificate of Incorporation, and identify and attach as
an Appendix. If private ownership, please also identify the Principle
Shareholders below. | |Name | |
| |City | |Province/Sta| |
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| |Countr| | | |
| |y | | | |
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