DEPARTMENT OF HEALTH (DOH)

CENTRAL OFFICE BIDS AND AWARDS

COMMITTEE (COBAC)
SAMPLE FORMS
REPUBLIC OF THE PHILIPPINES )
CITY/MUNICIPALITY OF ______ ) S.S.
x------------------------x

SWORN STATEMENT
(on Observance & Respect to the DOH Code of Conduct and
Confirmation on No Engagement with Tobacco Industry)

I, [Name of Affiant], the Authorized Representative, of [Name of Company], with an office

address at [Address of the Company], after having been duly sworn in accordance with law, do
hereby depose and state that:

I, on behalf of our company, is participating in the Public Bidding of the Department of Health
(DOH) for the procurement of under IB No. _______;

I, hereby pledge to observe and respect the Code of Conduct of the DOH such as but not limited
to the rule of “Conflict of Interest’ and “No Gift-Giving Policy”;

I, confirm that our company does not have any current engagement and/or partnership, joint
sponsorship or any other activity with the tobacco industry;

In the event that our company violated the afore-mentioned rules or found to have a
misrepresentation against this pledge, it shall be a ground for an automatic disqualification of our
bid without prejudice to the institution of an administrative, civil or criminal action;

That I am executing this affidavit to attest to the truthfulness of the foregoing and to comply
with the post-qualification requirement for the procurement of ________________ under IB No.
_______.

In witness whereof, I have hereunto affixed my signature this ______ day of 20_____ at the
_________________.

_____________________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of [month] [year] at [place of
execution], Philippines, affiant was identified by me through competent evidence of identity as
defined in the 2004 Rules on Notarial Practice (A.M. No. 02-8-13-SC). Affiant/s exhibited to me
his/her [insert type of identification card used], with his/her photograph and signature appearing
thereon, issued on ____ at ______.

Witness my hand and seal this ___ day of [month] [year].

NAME OF NOTARY PUBLIC

Serial No. of Commission _______________
Notary Public for _______ until __________
Roll of Attorneys No. __________________
PTR No. ______ [date issued], [place issued]
IBP No. ______ [date issued], [place issued]

Doc. No. _____

Page No. _____
Book No. _____
Series of _____

Note: Please use the template provided to minimize errors or omissions in the form submitted
 COMPUTATION OF NET FINANCIAL CONTRACTING CAPACITY

Summary of the Supplier’s/Distributor’s/Manufacturer’s assets and liabilities on the basis of the

income tax return and audited financial statement, stamped “RECEIVED” by the Bureau of
Internal Revenue or BIR authorized collecting agent, for the immediately preceding year.

Year 20___
1 Total Assets
2 Current Assets
3 Total Liabilities
4 Current Liabilities
5 Net Worth (1-3)
6 Net Working Capital

The Net Financial Contracting Capacity (NFCC) based on the above data is computed as follows:

NFCC = [(Current Assets minus Current Liabilities) (15)] minus the value of all outstanding or
uncompleted portions of the projects under on-going contracts, including awarded contracts yet
to be started coinciding with the contract to be bid.

Where:

K = 15

NFCC = PhP__________

_______________________
Signature over Printed Name
[date of signing]

In the capacity of :[title or other appropriate designation]

Duly authorized to sign bid for and on behalf of :[Name of Company]
[Complete office address]
[Contact No.]
[Fax No.]
[Email Address]

Note: Bidders are highly encouraged to use the template provided to minimize errors or omissions in the form
submitted. However, bidders may use their own template for as long as the essential portion/details of the
said document are present.
 MANUFACTURER’S CERTIFICATE/AUTHORIZATION
(In case the bidder is appointed by the Manufacturer as an
authorized distributor)

Manufacturer's Authorization

To: [name and address of Procurement Agent]

We [complete name of Manufacturer], who are official manufacturers of [type of goods

manufactured], having factories at [full address of Manufacturer’s factories], do hereby appoint
[complete name of Bidder] as the authorized distributor of [Importer/Distributor and address] to
participate in Government Bidding for the following Goods/Products [name and or brief
description of the Goods], manufactured by us and to subsequently enter into a Contract with the
DEPARTMENT OF HEALTH.

This authorization/certification is valid for [years] from the [date of issuance] and being
issued to [Bidder] unless revoked for any justifiable reason(s) by either party.

Notes: 1) If the Main Importer/Distributor is also the bidder, the existing Distributorship Agreement/Certificate
of Exclusive Distributorship with the Manufacturer (whichever is applicable), may be submitted in lieu
of this form.
2) This letter of authority should be on the letterhead of the Manufacturer.
3) Bidders are highly encouraged to use the template provided to minimize errors or omissions in the
form submitted. However, bidders may use their own template for as long as the essential
portion/details of the said document are present.

______________________
Signature over Printed Name
[date of signing]

In the capacity of :[title or other appropriate designation]

Duly authorized to sign bid for and on behalf of :[Name of Company]
[Complete office address]
[Contact No.]
[Fax No.]
 AUTHORIZATION FROM THE MAIN DISTRIBUTOR
(In case the bidder is a Value Added Reseller/Reseller
appointed/authorized by the Main distributor)

Authorization from the Main Distributor of the Manufacturer

To: [name and address of Procurement Agent]

We [complete name of Main distributor], who are main/principal distributor of [type of

goods distributed] manufactured/developed by [Manufacturer/Owner’s Name ], located at [full
address of Main distributor], do hereby appoint/authorize [complete name of Bidder] a Value
Added Reseller/Reseller to participate in Government Bidding for the following Goods/Products
[name and or brief description of the Goods], distributed by our company and to subsequently
enter into a Contract with the DEPARTMENT OF HEALTH.

This authorization/certification is valid for [years] from the [date of issuance] and being
issued to [Bidder] unless revoked for any justifiable reason(s) by either party.

Notes: 1) If the Main Importer/Distributor is also the bidder, the existing Distributorship Agreement/Certificate
of Exclusive Distributorship with the Manufacturer (whichever is applicable), may be submitted in lieu
of this form.
2) This letter of authority should be on the letterhead of the Main distributor.
3) Bidders are highly encouraged to use the template provided to minimize errors or omissions in the
form submitted. However, bidders may use their own template for as long as the essential
portion/details of the said document are present.

______________________
Signature over Printed Name
[date of signing]

In the capacity of :[title or other appropriate designation]

Duly authorized to sign bid for and on behalf of :[Name of Company]
[Complete office address]
[Contact No.]
[Fax No.]
REPUBLIC OF THE PHILIPPINES )
CITY OF _______________________ ) S.S.
x-------------------------------------------------------x

SECRETARY’S CERTIFICATE

I, _________________________, a duly elected and qualified Corporate Secretary of

____________________________, a corporation duly organized and existing under and by virtue
of the laws of the Republic of the Philippines, with principal office and place of business at
[complete office address], DO HEREBY CERTIFY, that:

I am familiar with the facts herein certified and duly authorized to certify the same;

At the Regular/Special meeting of the Board of Directors of the said Corporation duly
convened and held on [dd mm yy] at which meeting a quorum was present and acted throughout,
the following resolution was unanimously approved, and the same have not been annulled, revoked
and amended in any way whatever and are in full force and effect on the date hereof:

(Resolution No.___________)

RESOLVED, that ________________________be, as it hereby is, authorized to

participate in the bidding of the [Name of the Project and reference number] by the
DEPARTMENT OF HEALTH (DOH); and that if awarded the project shall enter into a contract
with the DOH; and in connection therewith hereby appoint _______________________, acting
as duly authorized and designated representatives of __________________, are granted full power
and authority to do, execute and perform any and all acts necessary and/or to represent
______________________ in the bidding as fully and effectively as the
_________________________________ might do if personally present with full power of
substitution and revocation and hereby satisfying and confirming all that my said representative
shall lawfully do or cause to be done by virtue hereof;

IN WITNESS WHEREOF, I/We have hereunto set my/our hands this ____ day of
[month] [year] at [place of execution].

____________________________
[Corporate Secretary]

SUBSCRIBED AND SWORN to before me this __ day of [month] [year] at [place of

execution], Philippines. Affiant/s is/are personally known to me and was/were identified by me
through competent evidence of identity as defined in the 2004 Rules on Notarial Practice (A.M.
No. 02-8-13-SC). Affiant/s exhibited to me his/her [insert type of government identification card
used], with his/her photograph and signature appearing thereon, with no. ______ and his/her
Community Tax Certificate No. _______ issued on ______ at ______.

Witness my hand and seal this ___ day of [month] [year].

NAME OF NOTARY PUBLIC

Serial No. of Commission ___________
Notary Public for ______ until _______
Roll of Attorneys No. _____
PTR No. __, [date issued], [place issued]
IBP No. __, [date issued], [place issued]

Doc. No. ___

Page No. ___
Book No. ___
Series of ____.

Note: Bidders are highly encouraged to use the template provided to minimize errors or omissions in the form
submitted. However, bidders may use their own template for as long as the essential portion/details of the
said document are present.
 REPUBLIC OF THE PHILIPPINES )
CITY OF _______________________ ) S.S.
x-------------------------------------------------------x

SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS that the undersigned [name], [title] of [name of
Company], is lawfully authorized to represent and act on behalf of the [name of company], a
company registered under the laws of the Republic of the Philippines with its registered office at
[complete office address], do hereby APPOINT, NAME and CONSTITUTE, [name], [title] of
[name of company] as my true and lawful attorney-in-fact to act for and in my name and stead, to
do, execute and perform any and all acts necessary and/or represent in the bidding and perform the
following acts:

1. To participate and submit a bid to the DEPARTMENT OF HEALTH for the

Procurement of [Name of Project and reference number].
2. To make, sign, execute, deliver and receive contracts, agreements and any and all
documents pertinent thereto, as may be necessary to carry into effect the foregoing
authority and to bind myself with the DOH.

HEREBY GIVING AND GRANTING unto my said attorney-in-fact full power and
authority to do and perform any and every act and thing whatsoever requisite or necessary or proper
to be done in and about the premises as fully to all intents and purposes as I might or could lawfully
do if personally present, with power of substitution and revocation, and hereby ratifying and
confirming all that my said attorney-in-fact shall lawfully do or cause to done under and by virtue
of these presents.

IN WITNESS WHEREOF, I/We have hereunto set my/our hands this ____ day of
[month] [year] at [place of execution].

___________________________
[Principal]
____________________________
[Legal Representative/s]

Attorney-in-Fact SIGNED IN THE PRESENCE OF

___________________________ ___________________________

SUBSCRIBED AND SWORN to before me this __ day of [month] [year] at [place of

execution], Philippines. Affiant/s is/are personally known to me and was/were identified by me
through competent evidence of identity as defined in the 2004 Rules on Notarial Practice (A.M.
No. 02-8-13-SC). Affiant/s exhibited to me his/her [insert type of government identification card
used], with his/her photograph and signature appearing thereon, with no. ______ and his/her
Community Tax Certificate No. _______ issued on ______ at ______.

Witness my hand and seal this ___ day of [month] [year].

NAME OF NOTARY PUBLIC

Serial No. of Commission ___________
Notary Public for ______ until _______
Roll of Attorneys No. _____
PTR No. __, [date issued], [place issued]
IBP No. __, [date issued], [place issued]

Doc. No. ___

Page No. ___
Book No. ___
Series of ____.

Note: Bidders are highly encouraged to use the template provided to minimize errors or omissions in the form
submitted. However, bidders may use their own template for as long as the essential portion/details of the
said document are present.
 Statement / List of all Ongoing Government and Private Contracts including contracts
awarded but not yet started (IF ANY)

Business Name : ________________________________

Business Address : ________________________________

a. Owner’s Bidder’s Role a. Date % of

Value of
Name Nature Awarded Accomplishment
Name of Outstanding
Contract b. Address of b. Date Started Works/
Description %
Project Cost c. Telephone Work c. Date of Planned Actual Undelivered
Nos. Completion Portion

Government

Private

Total Cost
Note: Indicate “no ongoing contracts” if there are none.

_______________________
Signature over Printed Name
[date of signing]

In the capacity of [title or other appropriate designation]

Duly authorized to sign bid for and on behalf of: [Name of Company]
[Complete office address]
[Contact No.]
[Fax No.]
[Email Address]

Note: Bidders are highly encouraged to use the template provided to minimize errors or omissions in the
form submitted. However, bidders may use their own template for as long as the essential
portion/details of the said document are present.
Statement identifying the Bidder’s Single Largest Completed Contract similar
to the contract to be bid
Business Name : ________________________________
Business Address : ________________________________

a. Owner’s Bidder’s Role a. Amount at a. Date Awarded

Name Nature of Award b. Contract
Name of Contract b. Address b. Amount at Effectivity
Work Description %
c. Telephone Completion c. Date
Nos. c. Duration Completed
Government /
Private

Note: This statement shall be supported with any of the following documents:
1. Purchase Order and/or Contract of Agreement;
2. Certificate of Completion or End-user’s Acceptance;
3. Official Receipt/s issued for the contract

_______________________
Signature over Printed Name
[date of signing]

In the capacity of: [title or other appropriate designation]

Duly authorized to sign bid for and on behalf of: [Name of Company]
[Complete office address]
[Contact No.]
[Fax No.]
[Email Address]

Note: Bidders are highly encouraged to use the template provided to minimize errors or omissions in the
form submitted. However, bidders may use their own template for as long as the essential
portion/details of the said document are present.