[The following table shall be filled in for the Applicant, each member of a Joint Venture and each Specialized Subcontractor] Applicant’s Name: [insert full name] Date: [insert day, month, year] Joint Venture Member’s or Specialized Subcontractor’s Name: [insert full name] RFP No. and title: [insert RFP number and title] Page of pages [insert page number] [insert total number] Environmental, Social, Health, and Safety Performance Declaration in accordance with Section III, Qualification Criteria, and Requirements No suspension or termination of contract: An employer has not suspended or terminated a contract and/or called the performance security for a contract for reasons related to Environmental, Social, Health, or Safety (ESHS) performance the date specified in Section III, Qualification Criteria, and Requirements, Sub-Factor 2.5. Declaration of suspension or termination of contract: The following contract(s) has/have been suspended or terminated and/or Performance Security called by an employer(s) for reasons related to Environmental, Social, Health, or Safety (ESHS) performance since the date specified in Section III, Qualification Criteria, and Requirements, Sub-Factor 2.5. Details are described below: Year Suspended or Contract Identification Total Contract terminated Amount (current portion of value, currency, contract exchange rate and US$ equivalent) Contract Identification: [insert [insert amount [indicate complete contract [insert amount] year] and name/ number, and any other identification] percentage] Name of Employer: [insert full name] Address of Employer: [insert street/city/country] Reason(s) for suspension or termination: [indicate main reason(s)] Contract Identification: [insert [insert amount [indicate complete contract [insert amount] year] and name/ number, and any identification] percentage] Name of Employer: [insert full name] Address of Employer: [insert street/city/country] Reason(s) for suspension or termination: [indicate main reason(s)] [list all applicable contracts] … … …
[The following table shall be filled in for the Applicant, each member of a Joint Venture and each Specialized Subcontractor] Applicant’s Name: [insert full name] Date: [insert day, month, year] Joint Venture Member’s or Specialized Subcontractor’s Name: [insert full name] RFP No. and title: [insert RFP number and title] Page [insert page number] of [insert total number] pages Environmental, Social, Health, and Safety Performance Declaration in accordance with Section III, Qualification Criteria, and Requirements No suspension or termination of contract: An employer has not suspended or terminated a contract and/or called the performance security for a contract for reasons related to Environmental, Social, Health, or Safety (ESHS) performance the date specified in Section III, Qualification Criteria, and Requirements, Sub-Factor 2.5. Declaration of suspension or termination of contract: The following contract(s) has/have been suspended or terminated and/or Performance Security called by an employer(s) for reasons related to Environmental, Social, Health, or Safety (ESHS) performance since the date specified in Section III, Qualification Criteria, and Requirements, Sub-Factor 2.5. Details are described below: Year Suspended or terminated portion of contract Contract Identification Total Contract Amount (current value, currency, exchange rate and US$ equivalent) [insert year] [insert amount and percentage] Contract Identification: [indicate complete contract name/ number, and any other identification] Name of Employer: [insert full name] Address of Employer: [insert street/city/country] Reason(s) for suspension or termination: [indicate main reason(s)] [insert amount] [insert year] [insert amount and percentage] Contract Identification: [indicate complete contract name/ number, and any identification] Name of Employer: [insert full name] Address of Employer: [insert street/city/country] Reason(s) for suspension or termination: [indicate main reason(s)] [insert amount] … … [list all applicable contracts] …
InitialSelectionwastewatertreatment.docx