Loria Holdings - Supplier Questionnaire

• Organization

• Conducted on

  Date

• Prepared by

• Name Of Supplier

Address

• City:

• Province/State:

• Postal/Zip Code

• County

• Telephone #

• Fax #/Email:

• Primary Contact:

A. Additional Company Information

• Number of Years under current business name:

  Less than 1 year

  1 - 5 Years

  5 - 10 Years

  More than 10 Years

• Has your company operated under other business names?

  Yes

  No

  N/A

• If YES, list other name(s) under which your company has operated:

• Ownership:

  Corporation

  Subsidiary

  Division

  Partnership

  Sole Proprietorship

• If subsidiary of another company, provide the name of the parent company:

• Company Contact when requesting general support (Telephone and Email)

• Company Contact for Quality related information (Telephone and Email)

Key Personnel: List the principle individuals of your company below:

• Name:

• Present Position

• Years with Company

• Name:

• Present Position

• Years with Company

• Name:

• Present Position

• Years with Company

B. Product / Service Provision

• Type of Service

• Approximate square footage of facility:

Identify any major tier subcontractor that you normally utilize.

• Business Name

• Address:

• Telephone / Fax

• Type / Portion of Work/Services

• Business Name

• Address:

• Telephone / Fax

• Type / Portion of Work/Services

• Business Name

• Address:

• Telephone / Fax

• Type of Portion of Work/Services

C. Quality Management

• Do you have a certified Quality Management System (ISO9000, ISO-13485, or equivalent)?

  Yes

  No

  N/A

• If YES, specified the type of Quality Management System:

• Name of registering body:

• Expiration of current registration:

  Date

• Copies of Certification/Letter(s) of Approval etc. attached:

  Yes

  No

  N/A

• If YES, specified the type of Quality Management System:

• Name of registering body:

• Expiration of current registration:

  Date

• Copies of Certification/Letter(s) of Approval etc. attached:

  Yes

  No

  N/A

• If YES, specified the type of Quality Management System:

• Name of registering body:

• Expiration of current registration:

  Date

• Copies of Certification/Letter(s) of Approval etc. attached:

  Yes

  No

  N/A

• List codes and standards to which your company are qualified/certified (ASTM, API, ANSI, CSA, etc) including any sections/division. (eg CSA 47.1 Di. 2.1)

The company representative below attests to the accuracy of all responses given herein.

• Name:

• Title:

• Telephone:

• Email:

• Fax/Phone:

• Date of Questionnaire Submitted (dd-mm-yy)

  Date