EMNAMBITHI / LADYSMITH MUNICIPALITY VENDOR REGISTRATION APPLICATION FORM SUPPLIER S REGISTRATION NAME COMPANY REGISTRATION NUMBER THESE FORMS MUST BE COMPLETED AND SUBMITTED TO: SUPPLY CHAIN MANAGEMENT UNIT SUPPLY CHAIN MANAGEMENT UNIT ROOM NO. 218 LISTER CLARENCE BUILDING P O BOX 195 221 MURCHISON STREET LADYSMITH LADYSMITH 3370 3370 ENQUIRIES: Greta Viljoen SUPPLY CHAIN MANAGEMENT SECTION Tel: 036 6372231 [Ext. 1258]
FOR OFFICE USE RECEIVED BY:... (Name & Pay No.) DATE:... CAPTURED BY:... NAME OF ENTERPRISE:... DATE OF RECEIPT:... (Application Form) All questions are to be answered in detail and the application form must be signed. Note: No faxed registration form will be accepted. Emnambithi/Ladysmith Municipality will not be held responsible for any mislaid registration forms that have been couriered or posted. Please keep copies of the registration form and all supporting documents submitted, for your own records. Please ensure that the certification of correctness section is signed and dated. Please ensure that the Company Registration Document is certified and stamped by a Commissioner of Oath. Please complete the form fully in black ink. Incomplete / unreadable forms will be rejected. Please ensure that your Tax Clearance Certificate is renewed annually and submitted to the Emnambithi/Ladysmith Municipality. If a Company has more than one (1) office/branch, each office must submit a separate application form. Page 1
REQUIRED DOCUMENTATION CHECKLIST Please ensure that all applicable documents, as listed below, are attached to the registration form ALL documentation is to be provided in its original format Document Name (Please tick appropriate box) YES / NO Original Valid Tax Clearance Certificate Company Registration Certificate (i.e. CK1/CK2 for Close Corporations: Certificate of Incorporation, CM29 and Share Certificates for Companies, Deed of Trust for a Trust; Partnership Agreement for Partnerships etc. (whichever is applicable) Company Resolution of Signatories Original or Certified Copy of Letter of Good Standing from the Workmen s Compensation Commissioner or Its Agent Most recent municipal accounts for your business or your personal residence i.e. Rates, Water, Refuse, electricity (if applicable) Original Certified copy of CIDB (Construction Industry Development Board) Registration Applicable to Construction Companies only. Original Certified copy of ECB (Electrical Constructing Board) Registration and accreditation. Financial Documentation (Proof of Bank Account) Original Cancelled Cheque or Bank Statement (Stamped). Copy of Acceptable for Food Premises Certificate (Compulsory for VIP Catering Purposes) Original Certified copies of ID Documents of Members/ Directors /Owners /Partners/ Share Holders. B-BBEE (Broad-Based Black Economic Empowerment) Status Level Verification Certificate Page 2
1. BUSINESS PARTICULARS 1.1. Name of Business as Registered with Registrar of Companies / Close Corporation 1.2. Trading Name 1.3. Postal Address Postal Code 1.4. Physical Address Postal Code 1.5. 1.Telephone Number 15.2. Cellphone Number 1.5.3. Fax Number 1.5.4. Email Address 1.5.5. Website Address Page 3
1.5.6. Preferred Method of Communication E-Mail Fax Telephone 1.6. Contact Person 1.7. Income Tax Reference Number If a Sole Proprietor or Partnership please provide Personal Income Tax number/s. 1.8. Unemployment Insurance Fund Number. (If applicable) Please attach copy of registration form. 1.9. P.A.Y.E. Number (if applicable) Please attach copy of registration form. 1.10. VAT Registration Number (If applicable) 1.11. Compensation Commissioner Registration Number. (If applicable) Please attach copy of registration form. 1.12. CIDB / ECB Registration Number (If applicable) Please attach copy of registration form. Electrical Installation Companies to attached copy of accreditation. 2.1 Name of Banking Institution 2. BANKING DETAILS 2.2. Branch Name Branch Code 2.3. Account Number 2.5. Account Name (Name under which account is operated) NB: Provide an Original Cancelled Cheque or an Original Bank Statement NOT older than 60 days. Page 4
3. TYPE OF BUSINESS Please tick the appropriate box Private Company (Pty) Ltd Public Company Ltd Close Corporation CC Sole Proprietor Partnership Trust Co-operative Voluntary Associations Please ensure that certified copies of the appropriate documents dependent on type of business is attached (e.g. CK1/CK2 for Close Corporations; Certified copies of the Certificate of Incorporation, CM29 and Copies of Share Certificates for Public and Private Companies; Deed of Trust for a Trust and the Partnership Agreement for a Partnership). 4. PREVIOUS BUSINESS INFORMATION 4.1 Did your business exist under a previous name? 4.2. If YES what was the previous name? 4.3 Reason for name change YES NO 5.1 CLASSIFICATION OF BUSINESS 5.1.1. Classification for Emnambithi / Ladysmith Municipal Supplier Database (Mandatory) Core Business Area Sub Sector *Please refer to Annexure 1 for a COMPREHENSIVE LIST of Core Areas and their corresponding sub-sectors *Two (2) Core Business Areas to be indicated and a maximum of 5 sub-sector commodities from an Annexure 1 Page 5
5.2. EMNAMBITHI/LADYSMITH MUNICIPALITY SUPPLY CHAIN MANAGEMENT SUB-SECTOR COMMODITY LIST In order to assist in the classification process, the following must be completed. NB Any vendor may only register for a maximum of two (2) categories ANNEXURE 1 CATEGORY 1. CONSTRUCTION CORE Air conditioning System Electrical Contractors Plumbing & Water Installation Alarm/Security System/Access Evacuation System Pre-cast Concrete Manufacture Control CCTV Surveillance Fencing Pool, Fish Pond & Fountain Autoclaves General Building Work Road Marking & Signage Automatic Hangar Doors Glazing Traffic Signs & Signals Automatic Sliding Doors Hauling/Heavy Equipment Transport Roadworks Automatic Sprinkle Sand Supply Road Maintenance Brickwork/Masonry Incinerators Solid Waste Disposal Cabinet/Furniture Making Landscaping/Earthworks Roofing & Waterproofing Carpeting/Floor Covering Lift & Escalator Sewerage Installation/Reticulations Tiling Mechanical Contracts Steam Installations & Ancillary Equipment Ceilings & Partition Metalwork & Burglar Bars Steel Fabrication & Erection Cladding Contracts Painting & Plastering Stormwater Draining Demolition Site Cleaning Paving Compressed Air Installation Timber Contractor Concrete Works Other (Specify) CATEGORY 2. SERVICES - CORE Accommodation Protective Clothing, Uniforms Pest Control Conference Facilities Handyman Performance Management Advertising/Public Relation Horticultural Services Printing Auto Repairs & Services HV Fault Finding Jointing & Termination Photography Auto Electrical Hydraulic Repairs Insurance/Employee Benefits Graphic Design Bookkeepers Interior/Industrial Design Promotional Material Carpeting Cleaning Office Maintenance Trophies & Medals Cleaning Services Medical Equipment/Instruments/Supplies Signage Computer Supplies/Services Copywriting Publishing & Radio Publicity Corporate Gifts Entertainment Audio Visual Equipment Recruitment Agencies Marquee Tent / Stage / Sound / Real Estate Decoration Safety & Security Services Portable Toilets (Public) IT Hardware & Software Service HV & LV Switchgear Portable Toilets (VIP) IT Maintenance & Computer Equipment /Transformers Site Cleaning Catering IT Management Debt Collection VIP Catering IT Networking Distribution Halaal Catering Laundry Services / Dry Cleaning Digging of Graves Cleaning Equipment/Material Transport Taxis Educational Services Diesel & Petrol Engines - Repairs Transport Buses Fire Extinguishers & Refills Locksmith Services Transport - Trucks Upholstery / Blinds Media Liaison Telecommunication Wind Socks for the Aerodrome Mailing / Courier Services Travel Agencies Funeral Services Medical/Ambulance/Health Care Telephone & Data Line Maintenance Florist Substance Abuse Testing Equipment Tyre Supplies & Repairs Garden Services Personnel Services Other (Specify) CATEGORY 3. PROFESSIONAL SERVICES - CORE Accountants/Financial Advisor EDMS Consultants Service Pre-Employment Assessment Consultant Architects EAP Consultants Project Managers Attorneys/Legal Services Economists Quantity Surveyors Attorneys/Conveyancing Industrial Relations Consultants Teachers Archival Services Consultants Job Description Consultants Town Planners Business Info. Management Land Surveyors Training Providers Geotechnical ( Consultant) Legal Compliance Consultants Translation Services Civil/Structure (Consultant) Medical practitioners Organisations Development Consulting Electrical (Consultant) OHS Consulting Contractors Mechanical (Consultant) Pharmacists Other (Specify) Multidisciplinary ( Consultant) Cleaning Service Lawnmower Sales/Services Garden Tools & Equipment Generators & Pumps Sales/Services Page 6
Continued... CATEGORY 4. WHOLESALERS / TRADERS/RETAILERS Automotive Parts & Batteries Workshop Equipment Refuse Bulk Containers Groceries, Food Supplies Fuel Supplies Vehicle Equipment Trailers & Tractors Books, Paper & Stationery Furniture & Office Equipment Fire Protection & Detection Building Materials/Hardware, Paint Fencing Equipment Grass, Plants, Flower, Seeds & Fertilisers Domestic Appliances Fire Fighting Equipment Laundry Equipment Chemicals Consumables Power Tools Pesticides Food for Game Animals Pressure Cleaners Cleaning Materials Generating Sets Valves Electrical Supplies & Equipment Health Safety & Environment Supplies Pumps Industrial Catering Equipment Live Stock Other Fast Food Outlet Recreational Supplies Supermarket Bottled Water Restaurant Refrigeration & Air Conditioning 5.3. BUSINESS INFORMATION Please indicated your appropriate Sector Agriculture Mining & Quarrying Manufacturing Electricity, Gas & Water Construction Retail, Motor Trade & Repair Wholesaler Trade, Commercial Catering, Accommodation & Other Transport & Storage Finance & Business Services Community, Social & personal Other Sectors (s) Please Specify Page 7
6. LOCATION OF BUSINESS AREA Emnambithi / Ladysmith Municipal Area TICK Municipal Account no:... KwaZulu-Natal Province Outside Emnambithi / Ladysmith Municipal Area Municipality Name:... Municipal Account No:... Other Province Within South Africa Municipality Name:... Municipal Account No.:... International Accredited By:... Accreditation No:... Page 8
7. BUSINESS INFORMATION THE FOLLOWING TABLE MUST BE COMPLETED IN ORDER TO ESTABLISH WHETHER A BUSINESS CAN BE CLASSIFIED AS A SMME IN TERMS OF THE NATIONAL SMALL MICRO MEDIUM ENTERPRISE ACT 102 OF 1996.SELECT & TICK THE APPROPRIATE BLOCKS IN COLUMNS 2, 3 & 4 COLUMN 1 COLUMN 2 COLUMN 3 COLUMN 4 Sector/ Sub-sectors in accordance with the Standard Industrial Council CIRCLE WHERE APPLICABLE Agriculture Mining & Quarrying Manufacturing Electricity, Gas & Water Construction Retail, Motor Trade & Repair Wholesaler Trade, Commercial Catering, Accommodation & Other Transport & Storage Finance & Business Services Community, Social & Personal Other Sectors (s) Please Specify Total full time equivalent of paid employees TICK WHERE APPLICABLE Total annual turnover TICK WHERE APPLICABLE Total gross asset value (Fixed Property excluded ) TICK WHERE APPLICABLE MORE THAN 100 MORE THAN R4M MORE THAN R4M LESS THAN 100 LESS R4M LESS R4M MORE THAN 200 MORE THAN R30M MORE THAN R18M LESS THAN 200 LESS R30M LESS R18M MORE THAN 200 MORE THAN R40M MORE THAN R15M LESS THAN 200 LESS R40M LESS R15M MORE THAN 200 MORE THAN R40M MORE THAN R15M LESS THAN 200 LESS R40M LESS R15M MORE THAN 200 MORE THAN R20M MORE THAN R4M LESS THAN 200 LESS R20M LESS R4M MORE THAN 100 MORE THAN R30M MORE THAN R5M LESS THAN 100 LESS R30M LESS R5M MORE THAN 100 MORE THAN R50M MORE THAN R8M LESS THAN 100 LESS R50M LESS R8M MORE THAN 100 MORE THAN R10M MORE THAN R2M LESS THAN 100 LESS R10M LESS R2M MORE THAN 100 MORE THAN R20M MORE THAN R5M LESS THAN 100 LESS R20M LESS R5M MORE THAN 100 MORE THAN R20M MORE THAN R4M LESS THAN 100 LESS R20M LESS R4M MORE THAN 100 MORE THAN R10M MORE THAN R5M LESS THAN 100 LESS R10M LESS R5M Page 9
8.1. PROPRIETORS/SHAREHOLDERS/PARTNERS/SOLE PROPRIETORS/TRUSTEES/BENEFICIERIES (OWNER) List all persons who are OWNERS (as listed above) and, where applicable, provide proof of disability by a recognised related institution. If insufficient space, kindly attach a copy of this page signed by the person who signs on behalf of the business NAME ID. NUMBER DISABILITY INSTITUTION % SHAREHOLDING 8.2. PLEASE INDICATE ANY OWNER WHO HAS A CONTROLLING OWNERSHIP INTEREST IN ANOTHER BUSINESS NAME OF OWNER NAME & ADDRESS OF OTHER BUSINESS POSITION HELD BUSINESS TYPE % OF OWNERSHIP Page 10
8.3. HDI INFORMATION How many Full Time (FT) & Part Time (PT) Staff members are employed by the enterprise? STAFF MEMBERS HISTORICALLY DISADVANTAGED INDIVIDUALS OTHER PRIORITY NON PRIORITY MALE FEMALE FT PT FT PT FT PT How many Full Time (FT) & Part Time (PT) Women are employed by the enterprise? WOMEN HISTORICALLY DISADVANTAGED INDIVIDUALS OTHER PRIORITY NON PRIORITY BLACK FEMALE WHITE FEMALE FT PT FT PT FT PT How many Full Time (FT) & Part Time (PT) Disabled members are employed by the enterprise? DISABLED MEMBERS HISTORICALLY DISADVANTAGED INDIVIDUALS OTHER PRIORITY NON PRIORITY MALE FEMALE FT PT FT PT FT PT Disabled (a permanent impairment of a physical, intellectual or sensory function resulting in restricted use or lack of ability to perform in a manner considered normal for a human being). Page 11
9. PREVIOUS EXPERIENCE List the last contract awarded to you (the supplier) or other previous experience relevant to your core business EMPLOYER / DEPARTMENT CONTACT PERSON & TEL. NUMBERS RAND VALUE OF CONTRACT COMPLETED SUCCESSFULLY YES / NO YEAR 10. DECLARATION OF INTEREST 1. No quotation will be accepted from persons in the service of the State* 2. Any person, having a kinship with persons in the service of state, including a blood relationship, may make an offer or offers in terms of an invitation to quote. In view of possible allegations of favouritism, should the resulting contract or part thereof, be awarded to persons connected with or related to a person in service of the state, It is required that the vendor/supplier or their authorised representative declare their position in relation to the evaluating/adjudicating authority and/or take an oath declaring his/her interest. 3. In order to give effect to the above, the following questionnaire must be completed: 3.1. Full name (Vendor/Supplier or Authorised Representative as mentioned above)... 3.2. Identity Number :... 3.3. Name of Business :... 3.4. Company Registration Number :... 3.5. Tax Reference Number :... 3.6. VAT Registration Number :... 3.6.1. Are you presently in the service of the state?* Yes 3.6.2. If so, furnish particulars :... No... 3.7. Have you been in the service of the state for the past twelve months? Yes 3.7.1. If so, furnish particulars:... No Page 12
... 3.8. Do you have any relationship (family/friend/other) with persons in the service of the state and who may be involved with the evaluation and adjudication of quotations/bids. Yes 3.8.1. If so, furnish particulars :...... 3.9. Are you aware of any relationship (family, friend, other) between a supplier and any persons in the service of the state who may be involved with the evaluation and or adjudication of quotations/bids? Yes No 3.9.1. If so, furnish particulars :...... No 3.10. Are any of the company s Directors/Managers/Principle Shareholders/Partners/Trustees or Stakeholders in the service of state? Yes 3.10.1. If so, furnish particulars :... No... 3.11. Is any spouse, child or parent of the company s Directors/Managers/ Principle Shareholders/ Partners/Trustees or Stakeholders in service of the state? Yes 3.11.1. If so, furnish particulars:...... * MSCM Regulations: in the service of the state means to be a) A member of (i) Any municipal council; (ii) Any provincial legislature; or (iii) The national Assembly or the National Council of Provinces; b) A member of the board of directors of any municipal entity; c) An official of any municipality or municipal entity; d) An employee of 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); e) A member of the accounting authority of any National or Provincial public entity; or an employee of Parliament or a Provincial Legislature. No Page 13
CERTIFICATION I, THE UNDERSIGNED (NAME)... CERTIFY THAT THE INFORMATION FURNISHED IN THIS DECLARATION FORM IS TRUE AND CORRECT. I ACCEPT THAT THE STATE MAY ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE....... Signature Date...... Position Name of Business Page 14
11. CERTIFICATION OF CORRECTNESS OF INFORMATION AS PROVIDED I / WE THE UNDERSIGNED, WHO WARRANTS THAT I AM / WE ARE DULY AUTHORISED TO DO SO ON BEHALF OF THE SUPPLIER, CERTIFIES THAT THE INFORMATION SUPPLIED IN TERMS OF THIS DOCUMENT WITH ADDITIONAL INFORMATION IS CORRECT AND ACCURATE AND ACKNOWLEDGE 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/false then the Emnambithi/Ladysmith Municipality may, in addition to any remedies it may have: (i) (ii) (iii) (iv) Disqualify the supplier/contractor for a particular tender/contract/project it may be considered for, or which had been awarded to the supplier/contractor; Recover from the supplier /contractor all costs, losses or damages incurred or sustained by the Emnambithi/Ladysmith Municipality as a result of breach of the contract; Cancel the contract and claim any damages which the Emnambithi/Ladysmith Municipality may suffer by having to make less favourable arrangements after such cancellation: and/or; De-register the supplier registered on the Supplier Database. SIGNED ON THIS DAY OF 20 AT SIGNATURE OF AUTHORISED REPRESENTATIVE BEFORE A COMMISIONER OF OATH NAME IN BLOCK LETTERS SUPPLIER S NAME: Signed and affirmed to, before me at, on this day of year, by the deponent who has acknowledged that he/she knows and understands, the contents of this document, and he/she acknowledged that he/she has no objection to affirming, that he/she regards the affirmation to be binding on his/her conscience. F COMMISSIONER OF OATH FULL NAME: BUSINESS ADDRESS: CAPACITY: AREA: Page 15