TENDER FORM
Contractor's details: 
Name of the company/ name and surname 	
address 	
phone: 	
e-mail 	

In response to the inquiry no. APP1 / 13 / NCN31 / 2022, the subject of which is the delivery of the S-adenosylmethionine supplement 200 mg and the supply of a placebo to the above-mentioned supplement as part of a research project financed by the National Science Center entitled "Clinical effects and molecular mechanisms of S-adenosylmethionine action in patients with primary sclerosing cholangitis (PSC) ", implemented under the co-financing agreement No. UMO-2020/39 / O / NZ5 / 03594, and I offer:
Item Number	NAME	NET PRICE	THE NET VALUE	VAT RATE	VALUE 										WITH TAX	
1.

	TOTAL PRICE for the subject of the contract: Supplement called S-adenosylmethionine 200 mg in the amount of 43 200 tablets, meeting the following requirements in relation to the manufacture and form of packaging: 
1.	Packaging - S-adenosylmethionine 200mg (S-adenosyl-L-methionine disulphate Tosylate 400 mg) - 4,320 blister packs of 10 tablets in an enteric coating (total 43,200 tablets) - blister packs in cardboard boxes printed with the batch number. 
2.	Manufacturing in accordance with the Good Manufacturing Practice (GMP) standard in accordance with the Regulation of the Minister of Health on the requirements of Good Manufacturing Practice (Journal of Laws of 2015, item 1979, as amended).  Microbiological analysis of the supplied supplement required. Tablets may be coated to give an appearance identical to that of the placebo.
3.	Creating a list of serial numbers enabling the identification of the supplement. 
The subject of the order should have a shelf life of at least 18 months at the time of delivery.					
2.	TOTAL PRICE for the subject of the order: placebo for the supplement called S-adenosylmethionine 200 mg in the amount of 43,200 tablets, meeting the following requirements in relation to the production and form of packaging: 
1.	Placebo pack for S-adenosylmethionine - 4,320 blister packs of 10 tablets (total 43,200 tablets) - blister packs in cardboard boxes with printed batch number. 
2.	Manufacturing of a placebo with an appearance, taste and smell identical to the supplement - in accordance with the Good Manufacturing Practice (GMP) standard in accordance with the Regulation of the Minister of Health on the requirements of Good Manufacturing Practice (Journal of Laws of 2015, item 1979, as amended). Tablets may be coated to give an appearance identical to that of the supplement. 
3.	Creating a list of serial numbers enabling the identification of the placebo.
The subject of the order should have a shelf life of at least 18 months at the time of delivery.					
Order completion date:	
	Delivery of the subject matter of the contract to the Clinic of Hepatology and Internal Diseases of the UCK WUM. Expected date of delivery by the Contracting Authority - 3 months from the date of signing the contract. 		
Total					

Total gross remuneration for the task (in words) : ………………………………………………………….
…………………………………………………………………………………………………………………………………………………………….
Including:  delivery of the supplement (1 package) - net ………………… VAT rate ……… .. VAT value …………
delivery of a placebo (1 package) - net ………………… VAT rate ……… .. VAT value ………………………….
1.	The price includes all costs related to the execution of the order. 
2.	I declare that I have acquainted myself with the terms and conditions specified in the invitation to tender and I undertake to sign the agreement.
3.	I declare that I have familiarised myself with the terms and conditions of the Invitation to Tender  and I do not raise any objections to it.
4.	If the offer is selected, I undertake to conclude the contract at a place and time specified by the Warsaw Medical University.
5.	I declare that I meet the following conditions:
a.	my legal, economic and financial situation allows me to complete the order.
b.	I am not a related or subsidiary, jointly dependent or dominant entity in relation to the Contracting Authority within the meaning of the Accounting Act of 29 September 1994 (i.e. Journal of Laws of 2013, item 330, as amended);
c.	I am not in a relationship of fact or law with the Contracting Authority or members of its bodies, which may raise justified doubts as to my impartiality in the selection of the supplier of goods or services, in particular being in a marital relationship, relationship of kinship or affinity up to and including the second degree, relationship of adoption, custody or guardianship, also through membership in the bodies of the supplier of goods or services.
d.	I am not a related party or a partner in relation to the Contracting Authority in the meaning of the Commission Regulation (EC) No 800/2008 of 6 August 2008 declaring certain categories of aid compatible with the common market in application of Articles 87 and 88 of the Treaty (General block exemption Regulation).
e.	I am not related personally to the Contracting Athority within the meaning of Article 32 (2) of the Act of March 11, 2004 on tax on goods and services (Journal of Laws No. 54, item 535, as amended).
f.	I am not excluded from the above-mentioned proceedings pursuant to Art. 7 sec. 1 of the Act of April 13, 2022 on special solutions in the field of counteracting aggression against Ukraine and serving the protection of national security (Journal of Laws, item 835), according to which the contractor is excluded: 
•	listed in the lists referred to in regulation 765/2006 and regulation 269/2014 or entered into the list on the basis of a decision on entry in the list determining the application of the measure referred to in article 2. 1 point 3 of the above-mentioned the law; 
•	whose real beneficiary within the meaning of the Act of March 1, 2018 on counteracting money laundering and financing of terrorism (Journal Of Laws of 2022, item 593 and 655) is a person included in the lists specified in Regulation 765/2006 and Regulation 269/2014 or entered into the list or being such a real beneficiary from February 24, 2022, provided that it was entered into the list on the basis of a decision on the entry on the list deciding on the application of the measure referred to in Art. 1 point 3 of the above-mentioned the law; 
•	whose parent company within the meaning of Art. 3 sec. 1 point 37 of the Accounting Act of September 29, 1994 (Journal Of Laws of 2021, item 217, 2105 and 2106) is an entity listed in the lists specified in Regulation 765/2006 and Regulation 269/2014 or entered into the list or being such a parent entity from February 24, 2022, provided that it was entered in the list on the basis of a decision on entry on the list determining the application of the measure referred to in article 1. 1 point 3 of the above-mentioned the law.
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Date and legible signature of the Contractor