Appendix - B

Government of Haryana
Public Works (B&R Branch) Department

APPLICATION FORM FOR ENLISTMENT AS CONTRACTOR

Supporting Documents be annexed with the application form (Applications found
deficient in any respect are liable to be rejected without further correspondence)

CLASS Category

Photograph
1. Name of applicant

2. Nationality Indian Other

3. Address

4. Regd office
ii) Head
Office
(Attach separate paper for addresses of other offices)

5. Tel. No. Fax No.

6. E-mail address

7. Web. Site
8. Constitution: Individual Sole Proprietorship Concern
Partnership Firm Public Ltd. Company Private Ltd. Company
9. If partnership firm, names of the partners/ If Company, name of directors
1…………………………………… 2……………………………………
3…………………………… 4…………………………………
5………………………….. 6………………………………..
10. Is the individual/sole proprietor/any partner/director of company:
(a) Dismissed Government Servant Yes No
(b) Removed from approved list of contractors Yes No
(c) Demoted to a lower class of contractors Yes No
(d) Having business banned/suspended by
any government in the past Yes No
(e) Convicted by a court of law Yes No
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(f) Retired engineer/official from engineering Yes No

Department of Govt. of India within last Two years
(g) Director or partner of any other Yes No
Company/firm enlisted with PWD or any other department

(h) Member of Parliament or any State

Legislative Assembly Yes No

If answer to any of the above is ‘Yes’, furnish details on a separate sheet

11.(a) Name of person holding power of attorney

(b) Nationality Indian Other

(c) Liabilities
12. Name of Bankers with full address

13. Place of business

14. Full time technical staff in applicant’s employment Nos.

(a) Graduate engineers with minimum 10 years’ experience

(b) Graduate engineers with minimum 5 years’ experience [excluding (a) above]

(c) Diploma engineers with minimum’ experience 10 years

(d) Diploma engineers with minimum’ experience 3 years [excluding (c) above]

15. Does the applicant have sufficient TandP, Machinery, Equipment and
workshop as per requirements mentioned in the Enlistment Rules
for the class and category applied for Yes No
[Attach details on separate sheet]
16 (a) Whether already enlisted with PWD Haryana or any other department/ Organization
Yes No
(b) If yes, give details:
(i) Name of department/ Organisation
(ii) Class and category
(iii) Enlistment authority and address
(iv) Enlistment No. and date
(v) Date of validity
(vi) Tendering limit
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17. Is any person working with the applicant is a near relative of the officer/
official of Haryana PWD If yes, give detail Yes No
18. Enlistment Processing fee enclosed/ Application fee enclosed( if downloaded from
internet):-
Draft No. Date Amount Issuing Bank and Branch drawn In whose
Branch upon favour drawn

19. Details of Works completed, in progress and secured during the last 4 years (to be filled
in proforma as given in Annexure –B-2). This list should include all works whose gross
amount of work done is more than the required magnitude for the class in which
registration is required.
20. Certificates from clients in original or attested copy as per proforma given in Annexure-
B-3 for all eligible works.
21. Certificates:
(i) I/We (including all partners) certify that I/We have read the Rules of Enlistment of
Contractors in PWD as amended upto-date and shall abide by them.
(ii) I/We certify that the information given above is true to the best of our knowledge.
I/We also understand that if any of the information is found wrong, I am/ we are liable
to be debarred.
(iii) I/We certify that I/We will not get myself/ourselves registered as contractor(s) in the
Department under more than one name.
(iv) (a) I certify that I did not retire as an Engineer of Gazetted rank or as any
Gazetted Officer employed on Engineering or Administrative duties in any
engineering Department of the Government of Haryana during the last two years. I
also certify that I have neither such a person under my employment nor shall I employ
any such person within two years of his retirement except with the prior permission of
the Government. (For individuals seeking enlistment in their own name )
(b) We certify that none of the partners/Directors retired as an Engineer of
Gazetted rank or as any Gazetted Officer employed on Engineering or Administrative
duties in last two years. We also certify that we have neither under our employment
any such person nor shall we employ any person within two years of his retirement
except with the prior permission of the Government. (For partnership firms and
limited companies).

(Strike out whichever is not applicable)

Signature(s) of applicant(s) :
Name Signature Address
1.
2.
3.
4.
Date :
No. of Documents attached
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ANNEXURE-B-1
DOCUMENTS ATTACHED FOR ENLISTMENT

Sr. Document Yes No

No.
1. Proof of constitution:
a) In case of sole proprietorship/HUF: an affidavit executed
before a 1st Class Magistrate that the applicant is the sole
proprietor of the firm/Karta of HUF.
b) In case of partnership firm: (Submit attested copies)
i) Partnership deed attested by Notary Public
ii) Form ‘A’ or equivalent form issued by Registrar of
Firms
iii) Form ‘B’ or equivalent form issued by Registrar of Firms
iv) Form ‘C’ or equivalent form issued by Registrar of Firms

c) In case of Private/Public Ltd Co. Article of Association

duly attested by Notary Public.

2. Proof of residence
3. Proof of PAN No.
4 Proof of Identity
5 Proof of Property
6 Affidavit of having never been black-listed by any Govt.
Organisation
7 Power of attorney, if any attested by Notary Public

8 Three passport size photographs of power attorney holder/

authorized signatory

9 Bankers’ certificate from scheduled bank in the Performa given

in Annexure-B-4. The certificate should be on the bank’s
letter-head and in sealed cover and shall be addressed to the
concerned Enlistment Authority

10 Technical Staff:
i) List of full time technical staff/Designers with
qualification and experience of each
(ii) Attested copies of the degrees/diplomas of the technical
staff/Designers.
(iii) Declaration from the technical staff that they are
employed with the applicant.
(iv) Documents like PF subscription ,Copy of Income Tax
return with, IT form16 etc conclusively proving
employment of technical staff with applicant (Onus of
 5
submitting adequate proof lies with applicant)

11 (i) List of Machinery, TandP i/c steel centering and

shuttering, possessed by the Applicant.
(ii) Copy of purchase document etc (Onus of submitting
adequate proof lies with applicant

12 List of all near relatives working in PWD, including their

addresses.

13 Demand Draft for enlistment fee and application fee (if

downloaded from internet).

14 i) Original or attested copies of certificates for works done,

from concerned clients, in proforma as given in
annexure-B-3
ii) Attested copies of award letters for works included in
Annexure- B-2

15 Character and antecedents Certificates from the Magistrate or

Gazetted officer not less than the rank of the Executive Engineer
 6

ANNEXURE-B-2
(1)In case of enlistment- Works completed, in progress and secured during the last
four years
[Add additional sheets, if necessary]

S. Name of Date of Date of Reasons Tendered Gross Net Name,

No. work and start completion for delay Amount Amount amount designation
Agreement and of the received and complete
No. Stipu- Actual compen- comple- address of the
lated sation ted authority for
levied, if work whom the
any work was
done

Contractor’s Signatures
 7

ANNEXURE – B-3.

CLIENT’s CERTIFICATE REG. PERFORMANCE OF CONTRACTOR

Name and address of the

Client………..………………………………………………………………………..
Details of Works executed by Shri/M/s
……………………………………………………………………….
………………………………………….…………………………………………………
………………….
[Link] of work with brief particulars

2. Agreement No. and date

3 Agreement amount

4. Date of commencement of work

5 Stipulated date of completion

6 Actual date of completion

7 Details of compensation levied for delay

(indicate amount) if any

8 Gross amount of the work completed and

paid

9 Name and address of the authority under

whom works executed

10 Whether the contractor employed

qualified Engineer/Overseer during
execution of work ?

11. i) Quality of work (indicate grading) Outstanding / Very Good / Good /

ii) Amt. of work paid on reduced rates, Satisfactory / Poor
if any.

12. i) Did the contractor go for arbitration?

ii) If yes, total amount of claim
iii) Total amount awarded
13. Comments on the capabilities of the
contractor. Outstanding/Very Good / Good /
a) Technical proficiency Satisfactory / poor

b) Financial soundness Outstanding/Very Good / Good /

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Satisfactory / poor
c) Mobilization of adequate TandP Outstanding/Very
Good/Good/Satisfactory/Poor
d) Mobilization of manpower
Outstanding/Very
e) General behavior Good/Good/Satisfactory/Poor

Outstanding/Very
Good/Good/Satisfactory/Poor

Note : All columns should be filled in properly

‘Countersigned’ Signature of the

Reporting Officer with Office seal
not below the rank of Executive
Engineer.

Officer of the rank of Superintending Engineer or equivalent

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ANNEXURE – B-4

FORM OF BANKERS’CERTIFICATE FROM A SCHEDULED BANK

This is to certify that to the best of our knowledge and information

M/s./Sri……………..having marginally noted address, a customer of our bank are/is
respectable and can be treated as good for any engagement up to a limit of Rs…………
(Rupees…………………………….). This certificate is issued without any guarantee or
responsibility on the Bank or any of the officers.

(Signature)
For the Bank

Note: 1) Bankers’ certificates should be on letter head of the Bank, sealed in cover
addressed to enlistment authority.
2) In case of partnership firm, certificate to include names of all partners as recorded with the Bank.
 10

ANNEXURE – B-5

FOR CHANGE OF CONSTITUTION LIST OF DOCUMENTS/INFORMATION

REQUIRED TO BE SUBMITTED

A. DOCUMENTS TO BE SUBMITTED

1. Copy of proposed partnership deed duly signed/proposed Memorandum of

articles.
2. An undertaking sworn in before a 1st class Magistrate by all the partners to the
effect that the new firm will take over all assets and liabilities.
3. Dissolution deed/consent of retiring partners/death certificate in case of death of a
partner.

B. FURNISH THE FOLLOWING DETAILS IN RESPECT OF EACH

PARTNER WITH WHOM CONTRACTOR'S FIRM WANT TO ENTER
INTO PARTNERSHIP.

i) Whether he is enlisted with CPWD/MES/Railway/PandT/State PWD.

ii) Whether he is a dismissed Govt. servant and debarred by his employer for doing
business with a government department or government company or a statutory
organisation.
iii) Whether he is a partner/director of any other firm enlisted with this
Department/MES/Rly./PandT/State PWD.
iv) Whether he is member of Indian Parliament or State Legislature.
v) Whether his name has been blacklisted or removed from the approved list of
contractors or demoted to lower class or orders banning/suspending business with
him by any department in the past.
vi) Whether he is a dismissed/removed/retired Govt. servant within 2 years.
vii) Whether he has any relative working in PWD, if yes, give details.
viii) Whether he has any civil or criminal case pending in any court in India, if yes,
give details.

C. DOCUMENTS TO BE SUBMITTED AFTER THE PROPOSAL IS

AGREED IN PRINICIPLE BY THE COMPETENT AUTHORITY
1) Copy of the partnership deed duly attested by the Notary Public.
2) Fresh Bankers’ certificate from banker of the contractor indicating new
constitution..
3) Form A, B and C or equivalent as the case may be.
4) Acknowledgement from the Income Tax/ Sales Tax department for having noted
the change.
 11

Annexure- B-6
List of Machinery

Sr. Name of Make Model Capacity Quantity Present Year of

No. Machinery location manufacture
1 2 3 4 5 6 7 8
 12
ANNEXURE – C

HARYANA PUBLIC WORKS DEPARTMENT

APPLICATION FOR RENEWAL OF ENLISTMENT

(The applicant should study carefully the Rules of Enlistment and the list of documents to
be annexed with the application form before filling the form. Application found deficient
in any respect are liable to be rejected without any further correspondence)

CLASS CATEGORY ………………….

Photograph
[Link] of applicant

1(a) Details of enlistment with PWD

(i) Enlistment No. and date
(ii)Valid upto

2. Nationality Indian Other

3. Address

4. [Link]

5. Head office

6. Telephone Number Fax No.

7. Now E-mail address : ___________________________

8. [Link] : ______________________________

9. Constitution Individual Sole Proprietorship Concern

Partnership firm Public Ltd. Company Ltd. Company

10. If partnership firm, names of the partners/ 1

If Company name of directors 2
3 4
5 6
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11. (a) Name of person holding power of attorney

(b) Nationality Indian Other

[Link] of Bankers with full address

13. Place of business

14. Full time tech. staff in applicant’s employment Nos.

(a) Graduate engineers with minimum 10 years’ experience
(b) Graduate engineers with minimum 5 years’ experience [excluding (a) above]
(c) Diploma engineers with minimum’ experience 10 years
(d) Diploma engineers with minimum’ experience 3 years [excluding (c) above]

15. Does the applicant have sufficient TandP, Machinery, Equipment and
workshop as per requirements mentioned in the Enlistment Rules for
the class and category applied for Yes No
(attach details on separate sheet)

16. Is any person working with the applicant is a near relative of the officer/official of
PWD Yes No
If answer to above is Yes, give details
17.(i)Details of PWD Works completed, in progress and secured during the last
enlistment/revalidation period as per Annexure –C-2. This list should include all
works whose gross amount of work done is more than the required magnitude for the
class in which registration is required.
Whether above details enclosed ? Yes No
(ii) Certificate regarding performance of contractor for work included
in annexure - C-2, as per proforma of annexure C-4. Yes No
(iii) Details of tenders issued and / or submitted by contractor
(Proforma C-3) Yes No

18. Certificates:
i I/We (including all partners) certify that I/We have read the Rules of Enlistment of
Contractors in PWD as amended upto date and shall abide by them.
ii I/We certify that I/We will not get myself/ourselves registered as contractor(s) in the
Department under more than one name,
iii I/We certify that the information given above is true to the best of our knowledge.
I/We understand that if any information is found incorrect, our enlistment is liable to
be cancelled.
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iv I/We certify that I/none of the partners/Directors retired as an Engineer of Gazetted

rank or as any Gazetted Officer employed on Engineering or Administrative duties in
last two years. We also certify that we have neither under our employment any such
person nor shall we employ any person within two years of his retirement except with
the prior permission of the Government.

(Strike out whichever is not applicable)

Signature(s) of applicant(s) :

Name Signature Address

1.
2.
3.
4.
Date
No. of documents attached
 15

ANNEXURE – C-1

Documents attached for revalidation

[Link]. Document Yes No

1 Proof of constitution:
a) In case of sole proprietorship/HUF: an
affidavit executed before a 1st Class Magistrate
that the applicant is the sole proprietor of the
firm/Karta of HUF.
b) In case of partnership firm: (Submit attested
copies)
i) Partnership deed attested by Notary Public

ii) Form ‘A’ or equivalent form issued by

Registrar of Firms
iii) Form ‘B’ or equivalent form issued by
Registrar of Firms

iv) Form ‘C’ or equivalent form issued by

Registrar of Firms

c) In case of Private/Public Ltd Co. Article of

Association duly attested by Notary Public

2 Power of attorney, if any attested by Notary

Public

3 Three passport size photographs of power attorney

holder/ authorized signatory

4 Bankers’ certificate from scheduled bank in the

Performa given in Annexure-B-4. The certificate
should be on the bank’s letter-head and in sealed
cover and shall be addressed to the concerned
Enlistment Authority
5 Technical Staff:
i) List of full time technical staff/Designers
with qualification and experience of each
(ii) Attested copies of the degrees/diplomas of
the technical staff/Designers.
(iii) Declaration from the technical staff that
they are employed with the applicant.
(iv) Documents like PF subscription ,Copy of
Income Tax return with, IT form16 etc
conclusively proving employment of
technical staff with applicant (Onus of
submitting adequate proof lies with
applicant)
 16

6 (i) List of Machinery, TandP i/c steel centering

and shuttering, possessed by the Applicant.
As per Annexure B-6.
(ii) Copy of purchase document etc (Onus of
submitting adequate proof lies with
applicant

7 List of all near relatives working in PWD,

including their addresses.

8 Demand Draft for late fee (if applicable)

i) List of works completed and in progress in
PWD during the last four years (annexure
C-2)
ii) Certificate regarding performance as per
annexure B-3 of works included in annexure
C-2

iii) Certificate regarding tenders issued and

submitted by the contractors for the works
in PWD as per annexure C-3.
9 Character and antecedents Certificates from the
Magistrate or Gazetted officer not less than the rank
of the Executive Engineer
10 Attested copy of enlistment order.
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ANNEXURE C-2
WORKS COMPLETED AND IN PROGRESS IN PWD DURING THE LAST
FOUR YEARS

Sr. Name of Date of Date of Completion Reasons for Tendered Actual Name,
No Work Start Stipulated Actual delay and Cost Cost Address of
compensation Engineer in
levied, if any Charge

Signature of Contractor
 18

ANNEXURE C-3
Proforma for certificate regarding tenders issued and or submitted by the contractor for
works in PWD during last four years
[Link] Name of Work Date of Tender Estimated Cost Position of
Issued Submitted put to tender Tender

Signature of Executive Engineer

With full Address
And Seal
 19

ANNEXURE C-4
CONTARCTOR’S PERFORMANCE REPORT
FOR WORKS COMPLETED OR IN PROGRESS
(FOR REVALID ATION OF ENLISTMENT)
Part-I
(To be filled in by the Contractor and submitted to the Engineer-in Charge of the
Work)

1 Name of Contractor
2 Name of Work
3 Contract No.
4 Est. Cost put to Tender
5 Tendered Cost
6 Gross Amount of Final bill
Work done till date
7 Stipulated Start
Date of Completion
8 Actual Date of Completion
9 Amount of compensation
levied, if any
10 Amount of Reduced Rate
items, if any
11 Did the contractor go for
Arbitration
12 If so, total Claimed
Amount Awarded

Signature of Contractor

Part-II

i. Certified that the details given in Part-I have been verified and found to be
correct/ have been corrected wherever necessary.
ii. The Quality of work is Very Good / Good / Satisfactory / Poor

Signature of the Executive Engineer

In case of Class I and II Contractors
The Quality of work is Very Good / Good / Satisfactory / Poor

Signature of the Superintending Engineer

Note: The Performance report should be forwarded to the Enlisting Authority within
two weeks of its receipt from the contractor.