SUPPLIER APPLICATION FORM. IMPORTANT NOTES Please read carefully

Transcription

1 SUPPLIER APPLICATION FORM IMPORTANT NOTES Please read carefully To be completed by the applicant seeking registration as an approved supplier, The questionnaire must be completed in full and must be signed; 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 applicant; Registration on LEDA s database does not guarantee procurement opportunities; Supplier must comply with all the registration-criteria for registration to be finalised failure to do so may result in the application being declined. Documents may be mailed or hand delivered to the above address. Faxed documents will not be accepted A. SUPPLIER DETAILS Company/ supplier name: Company/Close Corporation Registration Number Vat registration number (if applicable): Income tax reference number: Web Address: Address: Telephone Number Fax Number Postal Address: (Compulsory) Business Physical Address (Compulsory Postal code Postal code Please indicate your appropriate sector with (tick) Company Classification ISO listed Importer Service Manufacturing Exporter Repairer Public Company(Ltd) Private Company(Pty) Ltd Close Corporation(cc) Joint Venture Consortium Sole Proprietor Please indicate your appropriate sector with (tick) Agriculture Mining and Quarrying Manufacturing Foreign Company Partnership Trust Section 21 Company Government/ Parastatals / Organ of State Co-operative Wholesale Trade, commercial Catering, Accommodation, other Transport and Storage 1

2 Electricity, Gas and Water Construction Retail, Motor Trade and Repair Finance and Business Services Community, Social And Personal Training and development Total number of full time Employees Total Annual Turnover Total Gross Asset Value No. of years in business Summary columns: core business In your own words please state your core business Fill the specific brand names that the company solely distributes, if applicable: B. LIST OF PARTNERS, PROPRIETORS AND SHAREHOLDERS NB: A separate attachment must be submitted where the provided space is not sufficient. C. DECLARATION OF INTEREST *Are you currently working as an employee in any organ of state? Yes No Have you worked in any organ of state for the past twelve (12) months? Yes No Do you have any relative working for an organ of state? Yes No Do you or any person connected with your company have any close relationship with any official working for the state? Yes No Is there any other relevant information that you would like to disclose? Yes No 2

3 Are you or your spouse currently servicing on any structures of the state? Yes No Is there any other relevant information that you would like to disclose? Yes No If yes, provide proof of approval by AO/AA to perform remunerative work outside the public service D. REQUIRED DOCUMENTS CHECKLIST Please tick submitted documents Document type Attached Original valid Tax Clearance Certificate from SARS Certified copies of B-BBEE certificate Certified copy of company registration certificate Company profile(max 4 pages) Certified copies of director s ID s Certified copy of accreditation certificate: where applicable such as performance award, health certificate, proof of acquired training, etc. Cancelled cheque or verification letter of bank (annexure 4) Any relevant independent agency ratings/ industrial endorsement Other (please specify): E. CONDITIONS The following important notes should be read carefully before the completion of this form A company profile/bee profile will not be accepted as replacement for this form. This form must be completed in full and signed by the owner(s) or authorized representative(s) of the enterprise. Full signature is required when alterations are made in this document. If the information required is not applicable to your business, clearly insert N/A in the appropriate spaces. A business registered on the database must notify LEDA within 14 (fourteen) days of any changes to information provided in the application form. Failure to comply may result in such a business being removed and/or blacklisted from the database. Business providing information intentionally incorrectly/fraudulently will be disqualified. LEDA has the right to visit the business premises to verify the information provided in this form. The database will be updated on quarterly basis. A summary of the supplier s info on the database will be posted for verifying. Changes can be made on the summary and faxed back to LEDA. Only on receipt of a signed changed summary, updates will be added to the database. LEDA serves the right to reject any application, which in its opinion failed to comply with the registration requirements or criteria. All forms must be submitted in original form, either posted or hand delivered. 3

4 F. COMMODITY LIST (MAXIMUM OF FOUR COMMODITIES WILL BE REGISTERED) PLEASE TICK THE RELEVANT BOXES Travel, car hire and Accommodation services Auto Repairs Maintenance and repairs (plumbing, carpentry, partitioning, painting etc) Advertising and media Facilities and Equipment services (mechanical, electrical, audio) Office Furniture and Equipment services Professional services (auditing, legal, finance, HR, etc) ICT: - Consulting, - Training Services, - Open Source support and development services - Data centre services and hosting - Network support services (LAN and WAN), - Hardware, software, cabling and consumables. Personnel Agencies Multi-media, audio-visual and Photo framing services Printing and Design services Catering services Graphic Design and Branding services Cleaning, gardening and hygiene services Conference venue and facilities Corporate gifts & Promotions Courier, Removals and Delivery services Events Planning, Product Launch and design services Security, Fire services Telecommunications services Printing, Design Services and Copy Writing Exhibition Stands Design and Decor Refrigeration and Air conditioning services Consumables, Stationery, grocery services Locksmith and general repairs Printing, Design Services and Copy Writing Exhibition Management Services Florist / Flower Services Publications/Newspaper services G. APPLICATION DECLARATION I declare that the information provided is complete and correct to the best of my knowledge. I understand that any false information supplied could lead to my application being disqualified Initials & Surname Signature (Authorised Signatory) Date (DD/MM/YYYY) 4

5 H. FOR OFFICE USE ONLY Verification Document type Verified Original valid Tax Clearance Certificate from SARS Certified copy of valid B-BBEE certificate Certified copy of company registration certificate Company profile(max 4 pages) Certified copies of director s ID s Certified copy of accreditation certificate: where applicable such as performance award, Health certificate, proof of acquired training, etc. Cancelled cheque or verification letter of bank (annexure 4) Any relevant independent agency ratings/ industrial endorsement Comment: : : Verification Date : Verified By : Verifier s Signature : Approved by : Approver s Signature :

6 I. BANKING INFORMATION Bank name: Branch name AFFIX OFFICIAL BANK STAMP HERE Branch code: Account Holder: Account Number: Account Type: Bank Official Name: Designation Signature: Reference Number/ Description to be used: OR CANCELLED CHEQUE AFFIX A CANCELLED CHEQUE HERE 6

7 SBD 4 DECLARATION OF INTEREST 1. Any legal person, including persons employed by the state¹, or persons having a kinship with persons employed by the state, including a blood relationship, may make an offer or offers in terms of this invitation to bid (includes an advertised competitive bid, a limited bid, a proposal or written price quotation). In view of possible allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons employed by the state, or to persons connected with or related to them, it is required that the bidder or his/her authorised representative declare his/her position in relation to the evaluating/adjudicating authority where- - the bidder is employed by the state; and/or - the legal person on whose behalf the bidding document is signed, has a relationship with persons/a person who are/is involved in the evaluation and or adjudication of the bid(s), or where it is known that such a relationship exists between the person or persons for or on whose behalf the declarant acts and persons who are involved with the evaluation and or adjudication of the bid. 2. In order to give effect to the above, the following questionnaire must be completed and submitted with the bid. 2.1 of bidder or his or her representative:. 2.2 Identity Number: Position occupied in the Company (director, trustee, shareholder², member):. 2.4 Registration number of company, enterprise, close corporation, partnership agreement or trust: Tax Reference Number: 2.6 VAT Registration Number: The names of all directors / trustees / shareholders / members, their individual identity numbers, tax reference numbers and, if applicable, employee / PERSAL numbers must be indicated in paragraph 3 below. ¹ State means (a) (b) (c) (d) (e) any national or provincial department, national or provincial public entity or constitutional institution within the meaning of the Public Finance Management Act, 1999 (Act No. 1 of 1999); any municipality or municipal entity; provincial legislature; national Assembly or the national Council of provinces; or Parliament. ² Shareholder means a person who owns shares in the company and is actively involved in the management of the enterprise or business and exercises control over the enterprise. 2.7 Are you or any person connected with the bidder YES / NO presently employed by the state? 7

8 2.7.1 If so, furnish the following particulars: Name of person / director / trustee / shareholder/ member: Name of state institution at which you or the person connected to the bidder is employed : Position occupied in the state institution:... Any other particulars: If you are presently employed by the state, did you obtain YES / NO the appropriate authority to undertake remunerative work outside employment in the public sector? If yes, did you attach proof of such authority to the bid YES / NO document? (Note: Failure to submit proof of such authority, where applicable, may result in the disqualification of the bid If no, furnish reasons for non-submission of such proof: Did you or your spouse, or any of the company s directors / YES / NO trustees / shareholders / members or their spouses conduct business with the state in the previous twelve months? If so, furnish particulars: Do you, or any person connected with the bidder, have YES / NO any relationship (family, friend, other) with a person employed by the state and who may be involved with the evaluation and or adjudication of this bid? If so, furnish particulars Are you, or any person connected with the bidder, YES/NO aware of any relationship (family, friend, other) between any other bidder and any person employed by the state who may be involved with the evaluation and or adjudication of this bid? 8

9 If so, furnish particulars Do you or any of the directors / trustees / shareholders / members YES/NO of the company have any interest in any other related companies whether or not they are bidding for this contract? If so, furnish particulars:... 3 Full details of directors / trustees / members / shareholders. Identity Number Personal Income Tax Reference Number State Employee Number / Persal Number 4 DECLARATION I, THE UNDERSIGNED (NAME) CERTIFY THAT THE INFORMATION FURNISHED IN PARAGRAPHS 2 and 3 ABOVE IS CORRECT. I ACCEPT THAT THE STATE MAY REJECT THE BID OR ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE... Signature. Position.. Date Name of bidder 9