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APPLICATION DOCUMENT

FOR

Empanelment of Suppliers

For

Medical Store Items

(1st April 2016 – 31st March 2019)

Medical Stores,

Kasturba Hospital, Sevagram

Distt. Wardha - 442102

Maharashtra

Phone :- 07152 – 284341 Ext. 243

msquotation@mgims.ac.in

medicalstore@mgims.ac.in

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INDEX

Sr.No. CONTENT

1. About Kasturba Hospital, Sevagram

2. General Information & Instructions

3. Eligibility for empanelment

4. Documents to be submitted

5. Submission of documents

INFORMATION TO BE FURNISHED BY THE

APPLICANT

PART – I : Basic Information

PART – II : Financial Information

PART – III : Enclosures

Undertaking (Annexure-A)

Details of Orders/ Completed during the Last Three years (

Annexure – B)

Abbreviations:

KHS Kasturba Health Society

KH Kasturba Hospital

MGIMS Mahatma Gandhi Institute of Medical Sciences

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REGISTRATION OF SUPPLIERS FOR SUPPLY OF MEDICAL STORE ITEMS

AT KASTURBA HOSPITAL, KHS, SEVAGRAM

Kasturba hospital, KHS, Sevagram invites applications for registration of

Manufacturers/Firms/Stockiest/wholesalers/ Suppliers/Chemists/Dealers / Retailers to enter

in to PRICE AGREEMENT for supply of branded/Generic drugs, surgical and chemicals

under mentioned categories.

Application form is free of cost and can be downloaded from website:

http://www.mgims.ac.in

Application for registration of Firms/Supplier along with certified copy of the mentioned

documents may be submitted personally or by post to address mentioned below:

OFFICE OF THE MEDICAL SUPERINTENDENT

KASTURBA HOSPITAL, SEVAGRAM DIST: WARDHA, MAHARASHTRA. PIN: 442102

Envelop should be labeled as “Expression of Interest for Empanelment”. Firms already

registered with us for the period 1st April 2016 – 31st March 2019should not reapply.

The application received will be scrutinized and VERIFIED for authentication of

information, including inspection of supplier’s business premises before acceptance/rejection

of application. Request for registration which are not accompanied with requisite documents

are liable to be summarily rejected.

After registration, the E-Tender excel spread sheet will be mailed to respective registered

supplier’s E-mail.

1.0 About Kasturba Hospital, Sevagram

Kasturba Hospital (KH) Sevagram is a nearly 1000 bedded hospital affiliated to Mahatma

Gandhi Institute of Medical Sciences (MGIMS) which is a teaching Medical College, located

in Wardha district of Maharashtra. KH & MGIMS are run by Kasturba Health Society

(KHS), which is an autonomous, government funded organization, established in 1969.

Kasturba Hospital provides medicines, surgical items, disinfectants and diagnostics for

patients through its Medical Stores. During 2016-2017 Medical Stores made total purchase

worth around Rs. 15.00 crores, and it is anticipated that the values will grow by at least 10%

annually.

2.0 General Information & Instructions :-

Category Category Name Sub-Categories Item Description A Oral Drugs Tablets All Tablets for oral use

Capsules All Capsules for oral use

Syrups All Syrups / Suspension

for oral use

Powders All Powders for oral use

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Category Category Name Sub-Categories Item Description B Parental Drugs Injections All Injections for

Parenteral use.

Intra-Venous (IV)

Intra-Muscular (IM)

Subcutaneous (SC)

Intradermal ( ID ) Intra

spinal route

Category Category Name Sub-Categories Item Description C Topical Drugs Eye-Ear-Nose Drops EEN Drops

Sprays Local/ Oral/Mucosal

Ointments Local/ Oral/Mucosal

Local Applicants Suppositories

Creams Local / Oral /Mucosal

Respiratory Solution Nebulizer Solutions

Inhalers Inhalers, Respules

Transdermal Patch Analgesic

Category Category Name Sub-Categories Item Description

D General Surgical 1 CSSD items Cotton, Gauze,

Bandage, Gloves,

Syringes, IV fluids

Category Category Name Sub-Categories Item Description E General Surgical

items- 2

Needles All sizes for parenteral

use

Syringes Disposable / Glass

Tubings & Catheters All catheters Ryle’s

tube, feeding tubes,

Catheter, O2 mask

Endotracheal etc.

Infusion devices All I.V. Sets, Blood

bag

Urology Stents All tubed Medical

devices for intra

operative use

Category Category Name Sub-Categories Item Description

F Suture Materials Sutures/Mesh/

Staplers

Surgical sutures, mesh

and staplers/Devices

Category Category Name Sub-Categories Item Description G Diagnostic Agents Imaging films CT/MRI/X-Ray Films

Radiology

Solutions

Any Chemical used in

processing of Radiology

films

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Testing – Strips E.g. Glucometer strips

used with a testing device

Testing – Kit A testing kit used without

any instrument for

diagnostic purpose

Category Category Name Sub-Categories Item Description

H Chemicals and

Anesthetic Gases

Antiseptic,

Disinfectants,

Dialysis solution

Plaster material

Halothane,

Sevoflurane,

Isoflurane

Phenyl, POP, Pt.

related and Hospital

disinfectant

Category Category Name Sub-Categories Item Description I INTERVENTIONAL Cardiology

Radiology

Stents, guide wires,

related consumables for

cath lab and

Interventional

procedures

Category Category Name Sub-Categories Item Description

J IMPLANTS and

DEVICES Implants and Devices related to Orthopedics, Dental and Physiotherapy

Screw, plates,

prosthesis, Hip and

Knee replacement, K-

wires and other

orthopedic consumables.

Dental appliances and

consumables.

Physiotherapy kits,

appliances

ii) Suppliers need to indicate on the enclosed proforma, the groups for which

empanelment is sought.

iii) Kasturba Hospital will call for tenders for the items in each group from empanelled

suppliers of that group. This procedure will be followed every year in April. It will

ensure that all suppliers of particular group item receive the Tender notification.

iv) Empanelment does not guarantee any other favorable treatment and neither does

assure receipt of orders. Tenders will be processed as per procurement rules framed

by Kasturba Health Society.

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v) Empanelment applications will be received throughout the year. Any new suppliers

can register themselves, at any time of the year. Existing empanelled suppliers can

add more groups at any time by filling up modification form and paying requisite

fees. However if registration is done after last closing date of said year Tender, then

he will not be considered in current comparative list. Tenderer will be eligible for any

Tender which is released after successful registration.

vi) Kasturba Hospital will charge an empanelment fees of Rs. 1000/- only with

REFUNDABLE SECURITY AMOUNT of Rs 10,000/- per group. Empanelment fees

is to be paid by Demand Draft drawn in favor of “Kasturba Health Society,

Sevagram”. Any unpaid dues will be deducted from the security amount. In event of

supplier being blacklisted/found guilty of malpractice, the security amount will be

forfeited.

vii) All information called for in the enclosed Proforma should be furnished against the

relevant columns. Please attach separate sheet if the space provided is insufficient. All

columns in the form are to be filled up. If applicant has no information to be filled in a

particular column, “Nil” may be mentioned. In case of columns not relevant in the

applicant’s case, it should be stated as ‘Not-Applicable’. No column should be left

blank. Applications can also be sent by registered post. However it is the

responsibility of Tenderer to follow-up and ensure registration till the last step. It is

advisable to send authorized personal for completing the formalities.

viii) The application should be typewritten/printed. Overwriting should be avoided.

Correction, if any, should be made by neatly crossing out, initialing, dating and

rewriting.

ix) All sheets of the form are to be signed by the authorized signatory.

x) The application should invariably be accompanied by the “Undertaking” on the

prescribed format (Annexure –A) on a Rs 100/- stamp paper.

xi) Suppliers should furnish list of five largest orders executed in past three years in the

prescribed format (Annexure – B)

xii) The complete application document will be available as soft copy and can be sent by

E-mail to suppliers on request. Please make all such requests by E-mail, by sending a

mail to msquotation@mgims.ac.in or medicalstore@mgims.ac.in with subject heading

“Request for Empanelment Form”

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xiii) KH, Sevagram reserves the right to verify the performance of Vendors and to call for

any further information. Any information / clarification required during evaluation

must be given expeditiously. Failure to cooperate may affect registration.

xiv) Empanelment will be for a period of three years (April 2016 – 31st March 2019)

IRRESPECTIVE of date of empanelment, subject to satisfactory service. If the

service provided by the vendor is found to be unsatisfactory or if at any time it is

found that information furnished by the vendor is incorrect, then KH, Sevagram

reserves the right to remove such vendors from the empanelled list without giving any

notice to the vendor in advance.

xv) KH, Sevagram will evaluate the applications based on the set criteria and will choose

to short list qualified suppliers.

xvi) Decision of KHS, Sevagram with regard to preparation of panel of the Suppliers shall

be final. KHS, Sevagram is not bound to assign any reasons thereof.

xvii) KHS, Sevagram reserves the right to accept or reject any or all the applications

without assigning any reasons thereof and no correspondence in this regard shall be

entertained.

xviii) KHS, Sevagram shall not be responsible for any postal delay or loss in transit.

Incomplete applications may be rejected summarily.

3.0 Eligibility for Empanelment

i) Should be a reputed manufacturer/wholesaler and possess manufacturing/wholesale

drug license from concerned drug controller.

ii) Supplier should be registered and authorized stockiest/distributor/ dealer. In support,

the supplier should submit evidentiary proof along with the application document.

iii) The supplier should preferably be in existence for the last three years. In support,

the supplier should submit evidentiary proof along with the application document.

iv) The supplier should be registered with Goods and Services tax (GST) registration

number/ any other bodies, as applicable (Please attach documentary proof).

v) An applicant should have neither failed to perform on any agreement nor should have

been expelled/debarred/black listed or banned during the last three years with KH,

Sevagram or Kasturba Health Society.

vi) Should be financially sound and the total annual turnover be adequate enough to

maintain uninterrupted supply. He should supply goods at Institutional rates

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vii) Should have adequate storage facility and capable of bulk supplies including cold

storage as applicable.

viii) Manufacturers need not have Dealership certificate. It is always preferable and

advised that manufacturers should quote directly to our charitable Institution for

ensuring uninterrupted supply and cost-benefit to the patients.

ix) Acceptance of payment by Cheque.

x) Quality assurance protocol followed in manufacturing and/or supply of goods.

4.0 Documents to be submitted

The following documents duly attested & certified should be enclosed along with the

application :

i) Attested photocopy of registration certificates with Food and Drug Administrator

(FDA).

ii) Audited financial statements / balance Sheet for the past three years along with last

three years Income Tax and Sales Tax Returns.

iii) Attested Photocopy of registration with relevant tax authorities i.e. Income Tax

(PAN) No. : Service Tax No. : VAT Registration No. and GST registration No..

iv) Any Dealership authorization letters from pharmaceutical companies. This document

should be submitted in ORIGINAL on company letter head clearly showing outward

no. along with sign & name of competent authority.

5.0 Submission of Documents

The application form duly filled in shall be submitted in a sealed envelope super

subscribing “ Expression of Interest for Empanelment” addressed to

The Medical Superintendent

Office of the Medical Superintendent

Kasturba Hospital, Sevagram

Dist: Wardha, Maharashtra – 442 102

Monday to Friday 9.00am to 5.00pm

Saturday 9.00am to 1.00pm

(Excluding Sunday and Holidays)

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KASTURBA HOSPITAL, SEVAGRAM

SUPPLIER EMPANELMENT FORM

VALID FOR 2016 - 2019

Part – I Basic Information

1. Name of Firm :

Sole proprietor / Partnership: …...……………………………………

2. Name of owner/ Partners Signature

1. …...…………………………………….. …...……………………………………

2. …………………..…………………...… …...……………………………………

3………………….…………………...…… …...……………………………………

Recent passport size Photo (Sole / All Partners)

3. Contact Details

Address …………………………………………………………….……………….

Landmark……………..……………… City / Place……………….……………….

District………..………………..…………… State……………………….………

.

Pin ……………………………………..…

Phone (Land Line)………….………...………….

Mobile no. ….…………………….…………………………………………….……….

E-mail ID……………………………………………

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4. Item groups for which registration is sought (Tick all that are applicable)

Item Group Group Name Item type

1 Group A Oral Drugs All Tablets / Capsules / Syrups/ Powders

for oral use

2 Group B Injectable Drugs All Injections for parenteral use

3 Group C Topical Drugs Eye Drops / Ear Drops / Skin ointments /

Local applications / Creams /

Respiratory Solutions / Inhalers,

Transdermal patch

4 Group D General Surgical items

1

Cotton, Bandage and Gauze cloth,

Gloves, Syringes, IV fluids

5 Group E General Surgical items

2

All disposable items such as needles,

tubing, Infusion devices, Catheters,

surgicals ( except Group-D items)

6 Group F Sutures materials All suture materials, Surgical Mesh,

Staplers

7 Group G Diagnostic agents All diagnostic agents including

Radiological films, radiology developing

solutions, Blood testing-kits, Glucometer

Strips

8 Group H Chemicals and

Anaesthetic gases

All chemicals, disinfections, sterilization

agents. Halothane/ Sevoflurane/

Isoflurane

9 Group I Interventional

Cardiology/ Radiology

Cath Lab consumables, Stents, Guide

wires, Interventional radiology

disposables, foams, coils.

10 Group J Implants and Devices Orthopedic Implants, Prosthesis, screw,

plates, nails and all consumables

Hearing-Aid, Dental and Physiotherapy

items

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Part – II Financial Information

5 Financial Turnover

2014 – 2015 ………………………………………….….……………….

2015 – 2016 ……………..…..………………………..………………….

2016 – 2017………………………………………………………………

6. PAN/TIN Number ………………………………………………………..

7. CST/ST Number ……………………………….…………………………

8. GST Registration No. ……………………………………………………

9. VAT clearance upto ………………………………………………………

Part – III Enclosures

Enclosed documents (attach in following order)

1. Demand Draft amount Rs. ……………… No. …………………

dated ………………….. drawn on Bank …………………………… in favor of

KASTURBA HEALTH SOCIETY, SEVAGRAM.

2. Attested copy of Registration certificate with FDA

3. Copy of PAN Card of supplier

4. Audited financial statement / balance sheet for past three years along with last

three year sales tax + Income tax returns.

5. Copy of GST, Sales Tax, VAT Registration. True copies of Sales Tax, VAT

clearance certificate UPTO 31/03/2017.

6. Certified copy of deed of partnership and if required C&F Agreement from

manufacturer, power of attorney, if applicable.

7. Any dealership authorization letters from pharmaceutical companies. SUBMIT

ORIGINAL on manufacturing co. letter head duly signed by competent authority

displaying his name and designation with stamp along with outward no.

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FOR OFFICE USE ONLY

The following items were checked and found to be in order.

1 Items and Empanelment fees amount Yes / No

2 Demand Draft / Cash receipt Yes / No

3 FDA Registration Yes / No

4 Tax assessment documents Yes / No

5 PAN Card Yes / No

6 Sales Tax documents Yes / No

7 VAT registration Yes / No

8 VAT clearance upto 31st March 2015 Yes / No

9 GST registration

10 Others (specify)- ……………………… Yes/No

All certificates should in order –

All mandatory license attached –

Fine due (if Any) - ___________________________________________________________

Checked and found all clear.

Checked by ………………. ……………Ritesh Ambulkar………..Date …………..…….

(Signature) (Name)

All certificates in order –

All mandatory license attached -

Fine due (if Any) -

Dues – Paid / Unpaid

Checked and found all clear. No dues pending.

Incharge pharmacist

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All certificates in order - Yes/No.

All mandatory licenses attached - Yes/No

Fine due (if Any) - Yes/No

Dues – Paid / Unpaid - Paid/Unpaid

Checked and found all clear. - No dues pending.

Medical Officer Incharge

All Finance related certificates in order - Yes / No

GST/Sales tax/VAT / Income tax related documents - Approved / Not approved

Remarks (in any) : ___________________________________________________________

Checked and found all clear. No dues pending.

All finance/ Audit related documents are clear.

Incharge Accounts section

Registration - Approved / Not approved

Remarks (if any) _____________________________________________________________

Medical Superintendent

Kasturba Hospital, Sevagram

Complete details saved electronically in “SUPPLIER DATA BASE”

Correct and complete information entered in E-mail account of msquotation@mgims.ac.in

Demand Draft received and forwarded to accounts section

Mr. Pravin Wankhede

Pharmacist and Data operator

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REGISTRATION PROCESS COMPLETED

ANNEXURE – A

(To be submitted on Rs. 100/- stamp paper)

UNDERTAKING

I/We have read, understood and accept Kasturba Hospital, Sevagram’s General Terms and

conditions contained in the application form. I/we do hereby declare that all the details

provided in this application form are true to the best of my / our knowledge and belief and

any misrepresentation of facts will render me/us liable to any action as may be deemed fit by

Kasturba Hospital, Sevagram

I/We, do hereby also accept that Kasturba Hospital has the right to accept or reject this

application and not to issue invitation to Tender/ Quotation to me/us.

I/We undertake to communicate promptly to Kasturba Hospital, Sevagram any changes in the

condition or working of the firm. It is certified that my/our Firm has NOT been found guilty

of malpractice, misconduct, nor blacklisted/ debarred by Public Health Department, Govt. of

Maharashtra / any local authority / other State Government, Central Government's

organizations. Also there are no police cases pending against us or our business in the country

which would render our firm as disqualified. The undersigned is fully authorized to sign and

submit this application, form on behalf of our organization. We authorize Kasturba Hospital,

Sevagram to approach individuals, employers, firms and corporations and any other as may

be deemed necessary to verify our competence and general reputation.

Signature ________________________

Name ________________________

Designation ________________________

Address ________________________

Seal ________________________

Place _____________

Date _____________

Note: In partnership firms, all partners should sign

1. 2. 3.

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ANNEXURE – B

List of Largest Orders / Contracts Completed during the Last three years

Signature:

Name (in Block Letters):

Designation:

Seal of Company/ Supplier:

S.No

.

Name of the Product(s)

Name of

Client

Total cost of the

Project (In Rs.)

Completion Period

Scheduled Actual

Date

Date

i)

II)

III)

iv)

v)