GITC Supplier Accreditation Application Form



Government Information Technology Conditions

(GITC)

Supplier Accreditation Application Form

May 2019

|Organisation Details |

|Entity Type: | Individual Company |

|(tick one) |Partnership Overseas Incorporated Company |

| |Trust Other |

|Date Established: | |

|Legal Entity Name: | |

|Trading Name: | |

|Organisation Number: | |ABN: | |

|ACN ARBN BN | | | |

|Website Address: | |

|Email Address: | |

|Organisation Details: |Please forward as part of your application a list of your organisation’s directors/owners/partners. |

| | |

| |If your entity is a trust please also provide a copy of the trust deed. |

| | |

|Key Contact Details |

|Primary Contact Details - Local Office (Hobart or TAS) Head Office (Interstate or Overseas) Other |

|Title & Name: | |

|Position: | |

|Email Address: | |

|Telephone: | |Mobile: | |

|Street Address: | |

|(if different to nominated | |

|organisation address details) | |

| |Street address line 1 |

| | |

| |Street address line 2 |

| | | | |

| |Suburb/town/locality | |State |

| | | | |

| |Postcode | |Country if outside of Australia |

|Postal Address: | |

|(if different to above) | |

| |Postal address line 1 |

| | |

| |Postal address line 2 |

| | | | |

| |Suburb/town/locality | |State |

| | | | |

| |Postcode | |Country if outside of Australia |

|Insurance |

|A copy of each certificate of currency for the insurances indicated below is to be forwarded with your application. Please note we cannot accept Tax|

|invoices or Renewal notices. |

|Mandatory Insurance | Public Liability (or Broad Form Liability) Insurance |

| |minimum $5 million (AUS) |

| |Policy Number: |

| | |

| | |

| |Name of Insurer: |

| | |

| | |

| |Named Insured: |

| | |

| | |

| |Sum Insured: |

| | |

| | |

| |Expiry Date of Policy: |

| | |

| | |

| |Specify any exclusions & deductibles to the above insurance policy: |

| | |

| | |

| | |

| | |

| | Workers Compensation Insurance (if required by legislation) |

| |Policy Number: |

| | |

| | |

| |Name of Insurer: |

| | |

| | |

| |Named Insured: |

| | |

| | |

| |Expiry Date of Policy: |

| | |

| | |

| |Specify any exclusions & deductibles to the above insurance policy: |

| | |

| | |

| | |

| | |

|GITC Signatory Details |

|Please list the name and position of the person/s authorised to execute a GITC Deed of Agreement in accordance with s.127 of the Corporations Act |

|2001 (Cth). |

|Persons authorised to sign the |Name: | |

|Deed of Agreement: | | |

| |Position: | |

| |Name: | |

| |Position: | |

|If your Company signs under seal,|Name: | |

|please indicate the person | | |

|authorised to use the Common Seal| | |

| |Position: | |

|GITC Status - Other Jurisdictions |

|Please indicate if your |Jurisdiction |Current Status |

|organisation has GITC, PSA or |(e.g. Commonwealth, NSW, | |

|similar status in other |Victoria etc) | |

|Australian jurisdictions: | | |

| | | |

| | | |

|Agency Contact |

|Please indicate the Tasmanian |Name: | |

|Government Department / Agency | | |

|representative you have dealings | | |

|with (if applicable): | | |

| |Position: | |

| |Phone: | |

| |Email: | |

Checklist

Please ensure you have included the following supporting documentation with your application.

Failure to provide supporting documentation will result in delay in processing your application.

Organisational details listing Directors, Partners etc.

Certificates of Currency for:

Mandatory:

Public Liability (minimum $5 million)

Workers Compensation

Person submitting application:

Name: __________________________________________________

Position: ________________________________________________

Date: ___________________________________________________

Contact number: __________________________________________

|Please forward this application |Contact: |Contracts Management Unit |

|to: | | |

| | |Department of Treasury and Finance |

| |Phone: |(03) 6166 4219 |

| |Email: |GITC.Applications@treasury..au |

| |Postal Address: |GPO Box 147, Hobart, TAS, 7001 |

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Department of Treasury and Finance Cabinet

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