Application for Registration on the KwaZulu-Natal Gaming and Betting Board s Supplier Database This form must be completed and submitted to: Pietermaritzburg Office Supply Chain Management Unit Ground Floor, South Tower Natalia Building PIETERMARITZBURG Durban Office Supply Chain Management Unit 3 Nolsworth Park Nolsworth Crescent UMHLANGA ROCKS Alternatively post to: Supply Chain Management Unit Private Bag X9102 PIETERMARITZBURG 3200 Enquiries: All queries can be directed to: Mr A David on (033) 345 2714, or Mrs D McEwen on (031) 583 1800. For office use: Application ACCEPTED REJECTED Name of supplier: KZNGBB database registration number: Captured by: Date: Approved by: Date:
Important notes: This form is to be completed by all entities seeking registration as an approved supplier on the KwaZulu-Natal Gaming and Betting Board s (KZNGBB) supplier database. The application must be completed in full and must be signed. Please use a black pen and complete form in block letters. Certain fields and documents are mandatory to certain business types only. If the information required is not applicable to your business, clearly indicate the symbol N/A in the appropriate space. If the space provided is left blank it will be regarded as information that is still outstanding and you WILL NOT be registered A company profile must accompany the registration form but will not be accepted as a substitute for the application form all fields on the application form MUST be completed by applicant; It should be noted that the KZNGBB reserves the right to accept or reject any application without being obliged to give any reasons in this respect; Suppliers will be notified whether their application was accepted or not by means of written confirmation by e-mail or post. Suppliers must comply with all the registration-criteria for registration to be finalized, failure to do so may result in the application being declined. The KZNGBB Suppliers Database will be used mainly for the purposes of identifying business entities that can be approached when price quotations for goods and services are to be invited. The fact that the business entity is registered as supplier/ service provider does not constitute any contractual relationship between that entity and the KZNGBB. All procurement will be subject to the supply chain management policy of the KZNGBB and applicable legislation. For procurement above the financial limit applicable to price quotations, as determined from time to time by the relevant Treasury, the KZNGBB will invite competitive bids by means of advertisement in the media and website. The onus is on the supplier to obtain copies of the bidding documents from KZNGBB. Any alterations made by the service provider must be initialled. The use of correcting fluid is strictly prohibited. It is imperative that only KZNGBB form with Original Signatures be submitted. Applications with copied signature will not be considered. Forms that are unsigned submitted by facsimile or electronically, will not be accepted. Please ensure that the form is signed by an authorised person(s). All supplier information will be treated as strictly confidential. KZNGBB Supplier Database Registration Form Page 2 of 13
Document submission checklist Suppliers are required to confirm below that the required information has been submitted: Document required Valid tax clearance certificate Certified copies of company registration Certified copies of ID documents of owners Company profile Annual Financial statements for 2 years BEE Rating certificate or similar Proof of banking (see section 8) Other (specify) Submitted (Yes/No) Confirmed (for office use) KZNGBB Supplier Database Registration Form Page 3 of 13
1. BUSINESS / ENTITY DETAILS Name of enterprise: Trading name: Registered address: Postal code: Postal address: Postal code: Municipal district: Telephone: Mobile number: Fax number: Email: Website: 2. COMPANY REGISTRATION DETAILS Please mark the block with (x) that is applicable to your business or firm AND ATTACH the relevant certified information. Type of entity Tick Information required Close Corporation (CC) Co Operative Business trust Non profit organisation One person Sole proprietary Partnership Public Company (LTD) Private Company (Pty) LTD Incorporated Other (specify, and attach certified proof of registration) Certified copy of CK1/CK2 document if applicable Certified copy of proof of registration with the directorate of Co operative Certified copy of trust document Certified copy of constitution document Certified copy of identity document Certified copy of partnership agreement Certified copy certificate of incorporation (CM1) Certified copy certificate of incorporation (CM1) Certified copy of certificate of incorporation (CM1 & CM29) Enterprise registration no.: VAT registration no.: Income tax registration no.: KZN database registration no.: Tax clearance certificate no.: Expiry date: KZNGBB Supplier Database Registration Form Page 4 of 13
3. OWNER DETAILS Please list all persons / entities that are owners in the business/trust and indicate their involvement in the management/operations of the business/trust. Proof of disability provided by a recognized related institution, in the case of handicapped persons, must be supplied. If there is insufficient space, kindly attach copy/copies of this page to this application, signed by the same person who signs on behalf of the business/trust. Individual (I) or Organisation (O) Full name / Name of business SA Identity no. / Business registration no. SA citizen before 27 April 1994 (Y/N) Capacity: Member/ Partners/ Proprietor/ Shareholder/ Trustee/ Beneficiary Ownership %/ Partnership / Trust/ Interest Gender Disability Yes/No % of time devoted to the firm KZNGBB Supplier Database Registration Form Page 5 of 13
Additional ownership details Please indicate any owners who may have an interest in another business. Name of owner Name of other business Registration number of other business Position held Ownership % KZNGBB Supplier Database Registration Form Page 6 of 13
4. CONTACTS Main contact Surname: Name: ID number: Job title: Telephone no.: Cell no.: Email address: Sales contact Surname: Name: ID number: Job title: Telephone no.: Cell no.: Email address: Accounts contact Surname: Name: ID number: Job title: Telephone no.: Cell no.: Email address: KZNGBB Supplier Database Registration Form Page 7 of 13
5. COMPANY ESTABLISHMENT Date company established: Number of employees: Full time: Part time: Did the enterprise exist under another name? YES NO If yes: What was the previous name? Reason for name change? List of previous owners/partners/directors: Initials Surname Identity number Date resigned 6. FINANCIAL INFORMATION (Copies of latest financial statements for 2 years to be provided) Items Rand Amount Total gross asset value (excl. fixed property) Total fixed assets at book value Annual turnover Vehicles at book value Number of vehicles Average stock on hand Cost of goods produced annually Total current assets Total current liabilities 7. REFERENCES FOR PREVIOUS PROJECTS Provide details of at least 5 contracts/assignments completed in the last three years. Work performed Client Year Contact person Telephone KZNGBB Supplier Database Registration Form Page 8 of 13
8. BANKING DETAILS I/we hereby request and authorize you to pay any amounts which accrue to me/us to the credit of my/our bank account with the mentioned bank. I/we understand that the credit transfer hereby authorized will be processed by computer through a system known as Electronic Funds Transfer and I/we also understand that no additional advice of payment will be provided by my/our bank, but details of each payment will be printed on my/our bank statement or any accompanying voucher. (This does not apply where it is not customary for banks to issue bank statements.) I/we understand that a payment will be applied by KwaZulu-Natal Gaming and Betting Board in the normal way, and that it will indicate the date on which funds will be available in my/our account. Name of account holder: Bank name: Branch name & code: Account number: Account type: The section below is to be completed by your bankers I/we confirm that the above information on the clients account at this bank / building society is correct. Bank Stamp Signed on behalf of bank Name and surname Capacity / designation Telephone KZNGBB Supplier Database Registration Form Page 9 of 13
9. COMMODITY LIST Please indicate with the service/goods offered by your entity. (Please limit your selection to the 5 key activities of your entity). Category Goods/Service Tick GENERAL SERVICES Envelopes, business cards, & letterheads Newspapers & magazines Office equipment suppliers Office Equipment and Photocopying machines, printers and faxes supplies Printing companies Stationery Video conferencing Accommodation & Flights Car hire Travel Travel agents Venue hire Visa applications Catering services Catering Supply of meeting refreshments Supply of office refreshments Marketing & Advertising Billboard advertising Corporate gifts Exhibitions Graphic design Communications Layout and design of corporate publications Media campaigns Photography Reputation and Stakeholder management Transcription services Facilities Access control systems Air conditioning services & repairs Auctioneers Blinds installation Carpet / upholstery Cleaning CCTV systems Electrical services / contractors Facilities management and building systems Fire Equipment / systems Florists Furniture suppliers Furniture repairs General maintenance Interior designers Locksmiths Office maintenance Removal companies Pest control Plant hire KZNGBB Supplier Database Registration Form Page 10 of 13
Category Goods/Service Tick Plumbing services Repairs & sales of domestic & commercial appliances Security services Structural cabling Hygiene service Logistics Courier services Fleet management Offsite storage Professional services Supply Chain Supply chain benchmarking Supply chain business process development Supply chain consultants Supply chain system development Information Technology IT consultants IT peripherals Licensing Network cabling Software development Systems development / applications deployment Auditing Assets management Auditing Financial accounting Financial risk management Forensic audit Management accounting Human Resources Employee Assistance Program providers Facilitators: teambuilding & strategic planning Healthcare services HR consultants Industrial Relations; Facilitator, Mediator and Arbitrators Payroll outsourcing Recruitment advertising Recruitment, Selection and Placements Training and development / skills development Wellness programmes Legal Advocates Attorneys Research Strategy Corporate Strategy development Economic analysis Market analysis Industry / Sector specific Research Programme and Project Management Consultants IT programme and Project managers (Please specify) Other KZNGBB Supplier Database Registration Form Page 11 of 13
10. DECLARATION OF INTEREST 1. Are you or any person connected with the supplier presently employed by the state (Yes/No)? If yes, furnish the following particulars: i. Name of person / director / trustee / shareholder/ member: ii. Name of state institution at which you or the person connected to the supplier is employed: iii. Position occupied in the state institution: iv. Any other particulars: 2. If you are presently employed by the state, did you obtain the appropriate authority to undertake remunerative work outside employment in the public sector (Yes/No)? If yes, did you attach proof of such authority to the application(yes/no)? (Note: Failure to submit proof of such authority, where applicable, may result in the disqualification from registration). If no, furnish reasons for non-submission of such proof: 3. Did you or your spouse, or any of the company s directors / trustees / shareholders / members or their spouses conduct business with the state in the previous twelve months (Yes/No)? If so, furnish particulars: 4. Do you, or any person connected with the supplier, have any relationship (family, friend, other) with a person employed by the state and who may be involved with the evaluation and or adjudication of any bid (Yes/No)? If so, furnish particulars: 5. Are you, or any person connected with the supplier, aware of any relationship (family, friend, other) between any other supplier and any person employed by the state who may be involved with the evaluation and or adjudication of any bid (Yes/No)? If so, furnish particulars. 6. Do you or any of the directors / trustees / shareholders / members of the company have any interest in any other related companies whether or not they are applying for registration on the supplier database (Yes/No)? If so, furnish particulars: KZNGBB Supplier Database Registration Form Page 12 of 13
11. VERIFICATION OF INFORMATION I/We, the undersigned, who warrants that he/she is duly authorised to do so on behalf of the supplier, certifies that the information supplied in terms of this document including the annexures(s) with the additional information, is correct and accurate and acknowledges that: A. The supplier will be required to furnish proof of the information to preferences, if requested to do so. B. If the information supplied is found to be incorrect then the KwaZulu-Natal Gaming and Betting Board may, in addition to any remedies it may have to: i. Disqualify the supplier/ contractor for a particular bid/ contract/ project it may be considered for, or which had been awarded to the supplier/ contractor; ii. Recover from the supplier/ contractor all costs, losses or damages incurred or sustained by KwaZulu-Natal Gaming and Betting Board as a result of breach of contract; iii. Cancel the contract and claim any damages which KwaZulu-Natal Gaming and Betting Board may have suffered by having to make less favourable arrangements after such cancellations and or; iv. De-activate the supplier registered on KwaZulu-Natal Gaming and Betting Board. C. The deponent acknowledges that he/ she: i. Knows and understands the contents thereof; ii. Has no objection to taking the prescribe oath; iii. Considers the oath to be binding on his/ her conscience. SIGNED BEFORE THE COMMISSIONER OF OATHS Supplier representative: Initials: First name: Surname: Signature: Date: Signed at: I confirm that the deponent placed his/her signature hereon in my presence after acknowledging the contents thereof. Commissioner: Surname: Signature: Date: Signed at: Initials: Full name: Official stamp: KZNGBB Supplier Database Registration Form Page 13 of 13