DATABASE REGISTRATION FORM 2018 REF NO: ETVETC/2017/1/8 - LYDENBURG SATELITE FOR OFFICIAL PURPOSE SUPPLIER NUMBER

Transcription

1 1 DATABASE REGISTRATION FORM REF NO: ETVETC/2017/1/8 - LYDENBURG SATELITE NAME OF SERVICE PROVIDER : COMPANY NAME FOR OFFICIAL PURPOSE SUPPLIER NUMBER APPLICATION ACCEPTED APPLICATION REJECTED REASON IF REJECTED Captured By: Signature: Date:

2 2 SUPPLIER/SERVICE PROVIDER APPLICATION FORM IMPORTANT NOTES Please read carefully To be completed by all applicant seeking registration as an approved supplier; The questionnaire must be completed in full and be signed;failure to do so will result in the application being declined. A company profile may accompany the registration form but will not be accepted as substitute for the application form all fields on application form MUST be completed by the applicant; Applicants will be contacted via fax and and must therefore submit an operating fax number and address: failure to comply will result in excluding the suppliers from the data base; It should be noted that reserves the right to accept or reject any application without being obligated to give any reasons in this respect; A maximum of THREE (3) commodities must be reflected on the application form. Reflecting more that three commodities will nullify the application. Supplier must comply with all the registration criteria for registration to be finalised failure to do so will result in the application being declined; and A company registration certificate MUST be included in the application package. Only ORIGINAL application forms will be processed. Any document that has been retyped or redrafted will be disregarded and returned to the applicant. Only documents with an ORIGINAL signatures must be submitted. All signatures to the document must be commissioned by an authorized Commissioner of Oath. Failure to do so will result in the applicant not qualifying for registration A Proof of disability provided by a recognised related institution in the case of handicapped persons must be supplied Suppliers Information: Company / Supplier Name: Company / Close Corporation Registration No. Income Tax Reference (SARS) Number VAT Registration Number (if applicable) Web Address Address Telephone Address Code: Fax Number (compulsory) Code: CSD Supplier Number Number of full-time employees

3 3 Postal Address (compulsory) Physical Address (compulsory) Postal Code: Street Code: Main contact person in your company Name of contact person Company Position Cell Phone Number Code: Fax Number Code: Address Previous Experience (IF Applicable) If insufficient space, kindly attach a separate copy of the previous experience signed by the same person who signs on behalf of the business Company Name Contact Person Tel. Number Contract Value in Rand Completed Successfully Yes / No Year Company / Supplier Classification: (Please tick the relevant box or boxes) ISO Listed Importer Services Manufacturer Repairer Distributor Exporter Sales (Please tick the relevant box) Tax Clearence Certificate Attached Yes No Expiry date: Supplier Grouping Details: Type of Firm. Please tick the relevant box 1 Public Company (Ltd) 8 Sole Proprietor 2 Private Company (Pty) (Ltd) 9 Foreign entity 3 Close Corporation (cc) 10 Partnership 4 Co-operative 11 Trust 5 Joint Venture 12 Consortium 6 Section 21 Company 13 Other (specify) 7 Government / Parastatal

4 4 List all persons who are OWNERS in the business /trust, and indicate their involvement in the management /operations of the business / trust SMME status of your enterprise: Please use this table to determine the SMME status of your enterprise Please tick the relevant box in each column A. Sector B. Full time paid employees Medium Small Very Small C. Annual Turnover (millions) Micro Medium Small Very Small Micro D. Total Gross asset value (Property) excluded) (millions) Medium Small Very Micro Small Agriculture Manufacturing Construction Retail and Motor trade Catering Accommodation Transport Finance & Business Services Repair / Allied Services Communications Other Trade SMME status of your enterprise: (Please tick the relevant box) (According to SMME table) (Compulsory) Micro Very Small Small Medium Large

5 5 Points awarded for B-BBEE Status Level of Contribution In terms of Regulation 5 (2) and 6 (2) of the Preferential Procurement Regulations, preference points must be awarded to a bidder for attaining the B-BBEE status level of contribution in accordance with the table below: B-BBEE Status Level of Contributor (Attach Proof) Number of points (80/20 system) Non-compliant contributor 0 Bidders who qualify as EMEs in terms of the B-BBEE Act must submit a certificate issued by an Accounting Officer as contemplated in the CCA or a Verification Agency accredited by SANAS or a Registered Auditor. Registered auditors do not need to meet the prerequisite for IRBA s approval for the purpose of conducting verification and issuing EMEs with B-BBEE Status Level Certificates. Bidders other than EMEs must submit their original and valid B-BBEE status level verification certificate or a certified copy thereof, substantiating their B-BBEE rating issued by a Registered Auditor approved by IRBA or a Verification Agency accredited by SANAS.

6 6 A trust, consortium or joint venture, will qualify for points for their B-BBEE status level as a legal entity, provided that the entity submits their B-BBEE status level certificate. A trust, consortium or joint venture will qualify for points for their B-BBEE status level as an unincorporated entity, provided that the entity submits their consolidated B-BBEE scorecard as if they were a group structure and that such a consolidated B-BBEE scorecard is prepared for every separate bid. Tertiary institutions and public entities will be required to submit their B-BBEE status level certificates in terms of the specialized scorecard contained in the B-BBEE Codes of Good Practice. A person will not be awarded points for B-BBEE status level if it is indicated in the bid documents that such a bidder intends sub-contracting more than 25% of the value of the contract to any other enterprise that does not qualify for at least the points that such a bidder qualifies for, unless the intended subcontractor is an EME that has the capability and ability to execute the sub-contract. A person awarded a contract may not sub-contract more than 25% of the value of the contract to any other enterprise that does not have an equal or higher B-BBEE status level than the person concerned, unless the contract is sub-contracted to an EME that has the capability and ability to execute the sub-contract. BID DECLARATION Bidders who claim points in respect of B-BBEE Status Level of Contribution must complete the following: B-BBEE STATUS LEVEL OF CONTRIBUTION CLAIMED IN TERMS OF PARAGRAPHS TABLE ABOVE 7.1 B-BBEE Status Level of Contribution:. = (maximum of 20 points) (Points claimed in respect of paragraph 7.1 must be in accordance with the table reflected in paragraph below and must be substantiated by means of a B-BBEE certificate issued by a Verification Agency accredited by SANAS or a Registered Auditor approved by IRBA or an Accounting Officer as contemplated in the CCA). SUB-CONTRACTING Will any portion of the contract be sub-contracted? YES / NO (delete which is not applicable) If yes, indicate: (i) what percentage of the contract will be subcontracted?......% (ii) the name of the sub-contractor?.. (iii) the B-BBEE status level of the sub-contractor?. (iv) whether the sub-contractor is an EME? YES / NO (delete which is not applicable)

7 7 Broad-Based Black Economic Empowerment B-BBEE Status: Please read notes below very carefully before completing. Instructions and Definitions: Legislation: In terms of Section 38 of the PFMA the accounting officer of a department must ensure that the department has and maintains an appropriate procurement and provisioning system which is fair, equitable, transparent, competitive and cost-effective. Terminology: Commodities: The commodities the company wishes to be registered for as a supplier to the department. Trade Names: The trade names that the company owns or distributes, which you wish to be registered for as a supplier to the department. Owned: Having all the customary elements of ownership, including the right of decision making and sharing all the risks and profits commensurate with the degree of ownership interests as demonstrated by an examination rather than the form of ownership arrangements. B-BBEE Status Level of Contribution: means broad-based black economic empowerment as defined in section 1 of the Broad-Based Black Economic Empowerment Act B-BBEE Status Level of Contribution: means the B-BBEE status received by a measured entity based on its overall performance using the relevant scorecard contained in the Codes of Good Practice on Black Economic Empowerment, issued in terms of section 9(1) of the Broad- Based Black Economic Empowerment Act; EME: means any enterprise with annual total revenue of R5 million or less.

8 8 Documents to be attached The following documents must be attached to each application: Completed National Treasury Central Supplier Database (CSD) Registration Report (Form) Business registration including details of directorship and membership; Bank account holder information; Cancelled cheque/ 3 months certified bank statement; Proof of registration / accreditation/ affiliation to relevant professional institutions or regulatory; councils relevant to the type of services / commodity e.g. CIDB; Brief Company Profile, organogram and brochures; Certificate of incorporation from the Registrar of Companies (CIPRO); Tax compliance status e.g. Original Tax clearance certificate; Certified copies of ID document of company member(s) (ownership); BBBEE status level; Tender defaulting and restriction status; Certified Copy of Public Drivers Permit (PDP); VAT Registration BEE Rating Certificate and any other supporting documents A complete application must be hand delivered to the postal address mentioned below: 1193 Blio Street Mashishing Lydenburg Private Bag X 11297, NELSPRUIT 1200 PLEASE NOTE: No double application forms will be allowed. Only one application form will be issued to a Supplier /Service Provider. VERIFICATION OF INFORMATION SUPPLIED TO PREFERENCES THAT THE APPLICANT (BUSINESS) MAY APPLY FOR

9 9 I/we the undersigned who warrants that he / she is duly authorized to do so on behalf of the supplier, certifies that the information supplied in terms of this document including the annexure/s with additional information, is correct and accurate and acknowledge(s) that: 1. The supplier will be required to furnish documentary proof of the information relating to preferences if requested to do so. 2. If the information supplied is found to be incorrect then the college may, in addition to any remedies it may have: 2.1 disqualify the supplier / contractor for a particular tender/contract/project it may be considered for, or which had been awarded to the supplier / contractor 2.2 recover from the supplier / contractor all costs, losses or damages incurred or sustained by the College as a result of breach of the contract 2.3 cancel the contract and claim any damages which the College may suffer by having to make less favorable arrangements after such cancellation; and/or 2.4 De-register the supplier registered on the Supplier Database. 3. The B-BBEE claimed is in accordance with the new Preferential Procurement Policy Framework Act 2000 (PPPFA). 4. Any conflict of interest will be declared in the comment space below. Declaration of any conflict of interest: SIGNED ON THIS DAY OF 2017 AT BEFORE THE COMMISSIONER OF OATHS SIGNATURE OF OWNER OR AUTHORISED REPRESENTATIVE NAME & SURNAME OF OWNER OR AUTHORISED REPRESENTATIVE (NAME IN BLOCK LETTERS) SUPPLIER S NAME:

10 10 Signed and affirmed to, before me at on this day of year, by the deponent who has acknowledge that he/she knows and understands, the contents of this document and he/she has acknowledged that he/she has no obligation to affirming that he/she regards the affirmation to be binding on his /her conscience. COMMISSIONER OF OATHS FULL NAME OF COMMISSIONER BUSINESS ADDRESS CAPACITY : AREA: STAMP

11 11 Applications are invited from potential suppliers/service providers for the following services / commodities: LIST OF COMMODITIES -MAXIMUM THREE (Mark with X) DESCRIPTION X DESCRIPTION X Access Control Accountants/ Financial Advisory Services/Auditing Accommodation Accredited Service Providers Advertisement Agricultural Services and equipment Animal feed: Cattle, Chickens, Sheep, pigs and goats (Lucerne, bales etc.) Architects Annual reports: Concept, Design and Layouts Assessors Auctioneers Audio visual system Aqua cooler Borehole and Pump Maintenance Building Contractors Building and Maintenance Equipment Building Renovations Building Material and Hardware Blinds, Curtaining, Rails & Accessories Catering Car Rental Cartridges Cellular telephones and repairs Cleaning Material Cleaning Services and equipment Computers Consulting: Performance Management Consulting: Training & Development Consulting : Accountants Consulting: Auditors Corporate Gifts/Clothing Courier Services Crockery & Cutlery Cabling Data Projectors Decoder Machines Dictaphone Machine Digital Cameras DJ Services/ Entertainment Electrical Services / Maintenance Engraving & Trophies Event management & Functions Facilitation services Fire Extinguisher Furniture and Office Equipment Furniture removal Furniture repairs Gardening Services Hygiene Services IT Maintenance/ IT Software and Hardware/ IT Programming / IT Networking Insurance Companies Internet Service Provider

12 12 Consulting: engineers ( Civil, Electrical, Structural and Mechanical Consulting: Facilitators Consulting: Legal Consulting: Organizational Development Motor Vehicle Motivational Speaker Paper & Stationery Paving and Fencing Pest Control Photocopying Machine Photocopying Machine: Repairs and Services Plumbing / Sewerage drainage Printers Printer repairs and services Printing / Photography/ Graphic Design Printing: Brochure/ Business cards/ newsletter/ pamphlets Printing & supply of promotional material Project Manager Promotional Gifts Protective Clothing and uniform (PPE) Provision for Residence Public Relations / Marketing / Communication Quantity Surveyor Refurbishment of Buildings Renovations Services Office / Building Maintenance Management Consultancy Students Transport Students Accommodation Embroidery services Occupational Health & Safety Training Day-to-day Infrastructure Development & Maintenance Event Management Policy & Institutional Development Installation of security equipment Installation and repairs/ servicing of air conditioners, refrigerators and cold rooms etc. Legal Services Land Surveyor Landscaping Locksmith Services Office Equipment Office furniture PA Systems Partitioning Plumbing material/ Contractors Risk Management Security Services Sound & Recording Systems Supply of Textbooks Telecommunication Services Telephone Equipment Television Repairs Transport services Training and Development Travelling Agency Valuators (re-valuation of sites) Vehicle Towing Water Bottles Web design/ Maintenance Window / Glass Installation & Repairs Window / Glass Repairs Workshop: Material Workshop: Equipment Workshop: Consumables Construction Project Management Leadership and Management Training Communication Strategy Development Knowledge Management Strategy

13 13 OHS Act Compliance Certificate Fire Inspection Verification Screening / Security Check