Vápenka Vitošov s.r.o.

PREQUALIFICATION QUESTIONNAIRE

PREQUALIFICATION SAFETY QUESTIONNAIRE FOR SUPPLIERS

Data protection information

I hereby agree to my personal data being used in accordance with Vápenka VItošov s.r.o. data protection information.

1. About company

* Company name

* Address

* Number of employees

2. Company representative

* First name

* Surname

* Telephone number

* E-mail address

3. Reponsible person for safety

* First name

* Surname

* Job Title

* Telephone number

* E-mail address

4. Activities

* Please choose the activities you would like to perform:

Transportation

Maintenance, repairs, CAPEX

Previous experience in performing these activities (references):

5. Documentation

* Which of the following documents do you have available? (the documents must be submit to the Client without delay at the Client´s request)

Valid certification of OH&S Management System (e.g. OHSAS 18001)

Risk assessment relating to the work

Safe work procedure relating to the work

Rules of use of Personal Protective Equipment (PPE)

Liability Insurance

Records of revisions / technical inspections of machinery and equipment used at work

Records of daily pre-use vehicle check (only Contract Tranpsport)

6. Safety Management

* Information related to Safety Management System in your company. (mark to confirm validity)

We are acquainted with documents „HSE Conditions“ and „Tariff of Penalties“ and we commit to comply with them. (available on https://www.vitosov.cz)

We provide our employees with required PPE. (at minimum: high visibility clothing, helmet, safety glasses, safety shoes of category S3)

We do regular checks of our employees in relation with safety.

7. Accidents

* Do you have a procedure for reporting employee injuries and accidents?

Yes

* Please write down the number of employee injuries you have recorded in your company in the last 5 years (fatal accidents, lost time injuries)

* Have the authorities been imposing a fine for your company for breaching health, safety and environment regulations in the last 5 years? (please provide details)

8. Contact (responsible) person from VÁPENKA VITOŠOV s.r.o.

* First name

* Surname

9. Notes

Here you have opportunity to make any comments related with prequalification process:

10. Statement by the person completing this form

* I hereby certify that the above information given in the prequalification questionnaire are true and correct. I am committed to notify any changing work procedure, changing personnel or equipment.

* First name

* Surname

* E-mail address