APPLICATION FOR REGISTRATION AS SUPPLIER / SERVICE PROVIDER THE FOLLOWING PARTICULARS MUST BE FURNISHED (FAILURE TO DO SO MAY RESULT IN YOUR APPLICATION BEING DISQUALIFIED) NAME OF SUPPLIER/SERVICE PROVIDER... TRADING NAME OF SUPPLIER/SERVICE PROVIDER... COMPANY REGISTRATION / IDENTITY NUMBER POSTAL ADDRESS.. STREET ADDRESS (Which shall also serve as domicilium citandi et executant for all purposes of this application and any contract for the procurement of goods and/or services arising therefrom).. ADDRESS OF REGISTERED OFFICE (If different from street address) :... NAME OF CONTACT PERSON TELEPHONE NUMBER: CELL PHONE NUMBER FACSIMILE NUMBER E-MAIL ADDRESS WEBSITE DETAILS (If applicable) VAT REGISTRATION NUMBER*.. CODE NUMBER CODE.NUMBER..... INCOME TAX REFERENCE NUMBER*. CORE BUSINESS SPECIFIC EXPERTISE VESTED IN THE COMPANY QUANTITY AND FREQUENCY OF DELIVERY.. ANY OTHER INFORMATION
1. SUPPLIER REGISTRATION FORM Beyond Zero, hereby invites all prospective and current service providers to register on the Supplier Database. In order to comply with the revised Preferential Procurement Policy Framework Act, Beyond Zero will source quotations from the Company Supplier Database on rotational basis. Beyond Zero promotes B-BBEE initiative and would urge all SMME s to apply and register on the Company Supplier Database. Prospective service providers who successfully registered on Beyond Zero Supplier Database in 2013 must submit their updated information including the original valid Tax Clearance Certificate and a certified copy/ original B-BBEE certificate. Failure to submit the updated registration information could result in your information declared out- dated and further restricted from rendering any services for Beyond Zero. Suppliers Database forms are obtainable from Beyond Zero offices. Enquiries should be forwarded to: Region Name Telephone No -mail Address Fax Number East London Khuselwa Kumbala 043 704 540 khuselwan@beyondzero.org.za 043 721 2087 SUPPLIER REGISTRATION FORM Completed registration forms must be hand delivered or posted to the below mentioned postal addresses before closing date. Province Postal Address Physical Address Eastern Cape East London Port Elizabeth Kwa-zulu Natal Ixopo 57A Western Avenue Vincent East London 5200 60 2 nd Avenue Newton Park Port Elizabeth Office Suite 1 & 2 Lewis Store Building 39A Magaret Street Ixopo 57A Western Avenue Vincent East London 5200 60 2 nd Avenue Newton Park Port Elizabeth Office Suite 1 & 2 Lewis Store Building 39A Magaret Street Ixopo
SUPPLIER REGISTRATION FORM IMPORTANT NOTES Please read carefully before completion of registration form To be completed by all vendors seeking registration as an approved supplier; The supplier registration form must be completed in full and be signed, and forwarded to Beyond Zero Head Office in East London with all supporting documentation; A company profile must 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; Successful applicants will be contacted via fax and/or email and must therefore submit an operating fax number and/or email address; failure to comply will result in excluding the supplier from the Only successful suppliers will be notified in writing on their application been accepted; Information Checklist Telephone / Cell number as contact Physical address and Postal address Fax number or E-mail address Valid and Original SARS Tax Clearance Certificate Original or certified copy of B-BBEE certificate Original latest Bank Statement or Bank Letter with a bank stamp Company / CC Registration Certificate (Issued by CIPRO). Certified copy of identity documents (ID) of all shareholders / members / Directors or sole traders Latest entity s original or certified water /electricity Utility bill A Business profile of not more than five (5) pages Commodity listed only five (5) may be selected Location where goods and/or services may be required Fill all forms completely Sign all forms Submitted Yes No
2. SUPPLIER GROUPING DETAILS: (Please mark with an X the relevant box) 1. Public Company (LTD) 7. Foreign Company 2. Private Company (PTY) LTD 8. Joint Venture / Consortium 3. Closed Corporation (CC 9. Section 21 Company 4. Sole Proprietor 10. Government / Parastatals 5. Partnership 11. Co-operative 6. Trust 12. Other (Please specify) 3. BROAD-BASED BLACK ECONOMIC EMPOWERMENT (B-BBEE) VENDOR PROFILE List all partners / owners and shareholders (Compulsory) Name and Surname Position Citizenship ID Number Note: Where owners are themselves a company or partners, owners of the holding firm must be identified. Certified ID copies of partners, members, shareholders or owners must be attached 3. BROAD-BASED BLACK ECONOMIC EMPOWERMENT (B-BBEE) VENDOR PROFILE B-BBEE Status B-BBEE Recognition Level % Mark with an (X) Level 1 Contributor 135% Level 2 Contributor 125% Level 3 Contributor 110% Level 4 Contributor 100% Level 5 Contributor 80% Level 6 Contributor 60% Level 7 Contributor 50% Level 8 Contributor 10% Non-Compliant Contributor 0%
Exempted Micro Enterprise (EME) Any enterprise with an annual total Revenue of R5 million or less qualifies as an Exempted Micro- Enterprise (EME). A start-up enterprise must be measured as an Exempted Micro-Enterprise for the first year following its formation or incorporation. I/ We confirm that the information provided is correct as at this date: Name and Surname Signature Position Date 4. DECLARATION Verification of information supplied in this document, including attached documents: I/We, the undersigned, warrant that he / she is duly authorised to do so on behalf of the supplier, certifies that the information supplied including the annexure, is correct and accurate and acknowledge that: If I found that the information supplied is incorrect Beyond Zero will disqualify and remove the supplier from our database permanently. TERMS AND CONDITIONS Beyond Zero cannot guarantee business opportunities. All procurement will be subject to the company SCM policy, the general conditions of contract, and applicable legislation. All suppliers will be subjected to regular performance service review and could be deregistered if service levels are not maintained. The validity period of a quotation must be at least 30 (thirty) days Certified documents: Please ensure that The Commissioner of Oath has certified your company registration documents, Identity Documents and other copies. Verification of information supplied will perform against third party source such as SARS, CIPRO or CIPC, Safety net, etc. Please notify Beyond Zero immediately of any change to the provided information. Please ensure all fields are completed. Incomplete application forms will not be processed. Supplier Name: Signature of Authorised Representative Signatory Name in Print Signatory Position: Signatory ID Number: Signed at on this day of 20
PLEASE WRITE IN BLOCK LETTERS I/We hereby request and authorize you to pay any amounts, which may accrue to me/us to the credit of my/our account with the mentioned bank. I/we understand that the credit transfers hereby authorized will be processed by computer through a system known as "ACB - Electronic Fund Transfer Service", and I/we understand that not additional advice of payment will be provided by my/our bank, but that the 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 furnish bank Statements). I/we understand that Beyond Zero will supply a payment advice in the normal way, and that it will indicate the date on which the funds will be made available on my/our account. This authority may be cancelled by me/us by giving 30 days notice by prepaid registered post. Please ensure that the information is validated as per required bank screens. I/We understand that bank details provided should be exactly as per the records held by the bank. I/We understand that Beyond Zero will not assume responsibility for any delayed payments, as a result of incorrect information supplied. DECLARATION OF INTEREST 1. Any legal person, including persons employed by the company, or persons having a kinship with persons employed by the company, 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 company, 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 company; 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 Full Name of bidder or his or her representative: 2.2 Identity Number:.. 2.3 Position occupied in the Company (director, trustee, shareholder², member): 2.4 Registration number of company, enterprise, close corporation, partnership agreement or trust:
2.5 Tax Reference Number: 2.6 VAT Registration Number:..... 2.6.1 The names of all directors / trustees / shareholders / members, their individual identity numbers, tax reference numbers and, if applicable, employee / Personnel numbers must be indicated in paragraph 3 below. ¹ 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 Beyond Zero? 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 institution: Any other particulars: 2.7.2 If you are presently employed by the institution, did you obtain YES / NO the appropriate authority to undertake remunerative work outside employment in the public sector? 2.7.2.1 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. 2.7.2.2 If no, furnish reasons for non-submission of such proof:
2.8 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? 2.8.1 If so, furnish particulars: 2.9 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? 2.9.1 If so, furnish particulars. 2.10 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 institution who may be involved with the evaluation and or adjudication of this bid? 2.10.1 If so, furnish particulars. 2.11 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? 2.11.1 If so, furnish particulars:
3. Full details of directors / trustees / members / shareholders. Full Name Identity Number Personal Income Tax Reference Number Employee Number 4. SPECIAL CONDITIONS: 1. No advance payment would be made for the procurement of goods or services. Payment would be made in terms of the deliverables or other unless otherwise agreed upon by other parties (Beyond Zero and the contractor). Beyond Zero will pay within the prescribed period according to the agreement. 2. Service providers must complete and submit all relevant information/documentation required as insufficient information and non-compliance to the conditions set out will invalidate your application 3. Successful supplier providers enlisted of Beyond Zero supplier database must submit a new valid current Tax Clearance Certificate to the Head Office (East London) before the validity of the current Certificate expires, in order to ensure that Beyond Zero may continuously consider quotations submitted by your business. 4. It is imperative that only Beyond Zero supplier database registration form with supporting documentation and Original Signatures be submitted. Applications with copied signatures or any part of the supplier application that has been retyped or redrafted will not be considered and disqualified for re-registration. 5. Suppliers providing information incorrectly or fraudulently in their Supplier Database Registration form will be restricted from bidding, in addition to any other action Beyond Zero may institute against such a supplier. Furthermore, in the event of Beyond Zero being prejudiced financially, it reserves the right to take legal action against the supplier. BEYOND ZERO ANTI-CORRUPTION E-MAIL TIPOFFS@BEYONDZERO.ORG.ZA The aim of the E-mail is to enhance an honest work ethic and simultaneously provide employees and persons not employed by Beyond Zero with a mechanism to bring any unethical business practices to the attention of management.
DECLARATION I, the undersigned (name) Certify that i am aware of beyond zero anti-corruption email, where i can freely report possible corrupt actions by suppliers/service providers/contractors or possible corrupt actions within the company at any time and that the company will treat my identity as strictly confidential. Signature Date Position Name of Service Provide