FM 3.

01
Issue Date: May 2021
REV 1: May 2023

Third Party Provider Accreditation Form

INSTRUCTIONS
1 For Questions which are not applicable, please indicate NA. DO NOT LEAVE BLANK.
2 Please indicate all your answers in the fields in green.
3 Please complete and email the completed form to Ben Line requestor.

1] Legal Business Entity Information

[1.1] Company Details
Company Name :

Office address :

Country / City :

Post Code :

Phone :

Email :

Website :

[1.2] Key Contact

Title :

First Name :

Last Name :

Designation :

Department :

Email address :

Office Phone Number :

Mobile Phone Number :

2] Details of Products / Services

[2.1]Third Party Provider Classification

Third Party Provider Type : Service provider / Supplier / Consultant / Subagent / Others(Please specify)

Office Type : Head Quarters / Regional office / Country Office / Branch office
[2.2] Products / Services

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 Scope of Products / Services :
[2.3] Geographic Scope of Work
Country(s) of Services:
Ports Covered:
[2.4] Third Party Contractors
Will third party providers use any sub-contractors or sub-agents in the activities requested by Ben Line?
Yes/No:
If Yes, Sub-contractor/Subagent
Name :
Location subcontracted :
Scope of Service subcontracted :
3] Company Profile
[3.1] Third Party Provider Business Information
Business Licence Type : Sole Proprietor / Private Limited Company?
Place of Incorporation :
Incorporation Date :
Company Registration No. :
VAT / GST No. :
Business Licence Provide a copy

Does your company had any previous or current relationship with Ben Line Agencies, or any of the affiliated
companies?
Yes/No:
Details (if yes, Who & When):

Owner 1: PLEASE INPUT DETAILS ON SHAREHOLDERS

Nationality :
Percentage Ownership :
Previous Company Name :

Owner 2: PLEASE INPUT DETAILS ON SHAREHOLDERS

Nationality :
Percentage Ownership :
Previous Company Name :

Owner 3: PLEASE INPUT DETAILS ON SHAREHOLDERS

Nationality :
Percentage Ownership :
Previous Company Name :
Add as necessary
[3.2] Affiliates

Indicate nature (eg. Full name, type of business conducted) and relationship of any parent, subsidiary or affiliated
entities and describe their business operations
Affiliated Company Name 1 :
Type of Business :
Relationship :

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 Remarks :

Affiliated Company Name 2:

Type of Business :
Relationship :
Remarks :
Add as necessary
4] Insurance / Licences / Resources
[4.1] Insurance
1. Insurance Provider :
Coverage Type :
Policy No. :
Liability Value :
Next Expiry Date :
Insurance Policy Certificate Provide a valid copy

2. Insurance Provider :
Coverage Type :
Policy No. :
Liability Value :
Next Expiry Date :
Insurance Policy Certificate Provide a valid copy
Add as necessary
[4.2] Technical Capabillities
Licences / Permits
Name of Document:
Type of Document:

Licences / Permits
Name of Document:
Type of Document:
Add as necessary
[4.3] Resources / Capacity
Total Number of Full Time Employees :
Organisation Chart Provide a copy with key positions (with names and titles)

Type of Equipment (Boat, Vehicle, Crane etc.) - Below only to be filled up if applicable
Equipment
Description:
Quantity owned or leased:

Equipment
Description:
Quantity owned or leased:
Add as necessary

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 5] Billing Details
[5.1] Vendor banking information
Company Name:
Payment Address:
Telephone No.:
Email Address for remittance advices:
Bank Name & Branch:
Bank Address
Currency :
Swift Code:
Business Identifier Code (BIC)
- if applicable

Internal Bank Account No. (IBAN)

- if applicable

Account Number
Account Name

6] Legal Proceedings & Government Affiliations

[6.1] Litigation Background
Has the applicant or any subsidiary or affiliate of the applicant been the subject of past or pending litigation, or
government investigation?
Yes/No:

Details (if yes):

Has the applicant, or any subsidiary or affiliate of the applicant, or any owner, officer, director or employee of the
applicant's organisation ever been the subject of a criminal investigation, indictment or similar proceeding?
Yes/No:

Details (if yes):

Has the applicant, or any owner, officer, director or employee of the applicant's organisation ever been the subject of a
dishonourable discharge or dismissal from a military organisation or other government office?
Yes/No:
Details (if yes):

[6.2] Government Affiliations

Is any owner, officer, director, senior employee, representative or retained consultant of your company or one of its
affiliates also:
A current or former officer or employee of any government entity or candidate of political party /office?
Yes/No:
Details (if yes):

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A close relative of a current or former officer or employee of any government ministry, agency?

Yes/No:
Details (if yes):

A current or former officer or employee of a state-owned or state controlled enterprise?

Yes/No:
Details (if yes):

A member of or close relative of a member of a royal family?

Yes/No:
Details (if yes):

7] Health, Safety, Environment and Quality (HSEQ)

[7.1] ISO Accreditations
Please indicate if your company has any of the following accreditations:

ISO 9001 - Quality Management System

Yes/No:
Expiry date (if yes):
Provide Valid Copy

ISO 14001 - Environmental Management System

Yes/No:
Expiry date (if yes):
Provide Valid Copy

ISO 45001 Occupational Health and Safety Management System

Yes/No:
Expiry date (if yes):
Provide Valid Copy

8] Compliance
[8.1] Anti-Corruption & Bribery
Does your company have a policy prohibiting Bribery, Corruption and Improper Payments of any kind?
Yes/No:
If Yes, provide policy:

Does your company train employees regarding content and implications regarding ethics and / or anti-corruption
policies?
Yes/No:
Details (if yes):

Does your company conduct formal and informal assessments of ethical and anti-corruption risks within its
organisations?
Yes/No:
Details (if yes):

Does your company communicate ethics and/or anti-corruption policies to employees?

Yes/No:

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 Details (if yes):

Does your company have a system or program that allows its employees to ask questions or report concerns regarding
ethical or anti-corruption matters?
Yes/No:
Details (if yes):

Does your company require all subsidiaries, affiliates and your third party providers to comply with your ethics and/or
anticorruption policies?
Yes/No:
Details (if yes):

Has the Ben Line Agencies Form C "Anti-Corruption Certification for Business Partners" been signed?
Yes/No:
If No, Provide reason:

Provide any additional information that may assist us with evaluating your application :

Others
Payment Terms offered to Ben Line:

Credit Terms offered to Ben Line:

Relationship Details (For Ben Line internal use only)

Ben Line Requestor / Department:

Engagement or Relationship with

Third Party Provider Since :

Last Meeting Date :

Review Date :

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