Supplier Application 2009 New DATABASE FORM A&D; Postal Equipment SF/SG Information
User Manual: A&D; Postal Equipment SF/SG
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UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ Page 1 Attached is a Supplier Application Form to be completed, thus enabling you /your company to be registered on Umdoni Municipality’s Supplier Database, in respect of business classifications alluded to in Section C of the Application Form. ALL SUPPLIER INFORMATION WILL BE VERIFIED AND TREATED STRICTLY CONFIDENTIAL Attach an original cancelled cheque or stamped letter from the bank, verifying the banking details. Please note that any changes to bank details in future will be subject to the same requirement. COPIES OF THE FOLLOWING CERTIFIED DOCUMENTS MUST BE FURNISHED TOGETHER WITH YOUR APPLICATION: • Company Registration Documents (CK, CIDB etc.) • Identity documents of Directors/Owners/Members/ Shareholders • Most recently approved Annual Financial Statements • Value Added Tax (VAT) Registration Certificate (if applicable) • Tax Clearance Certificate • Compensation of Occupational Injuries and Diseases (COID) Registration Certificate • Rates account number, if residing within Umdoni boundaries • Levy Clearance Certificate, from the applicable District Municipality • Any other relevant Registration Certificate pertaining to your business • Copy of resolutions (if applicable) • Company Profile Completed Supplier Application Forms, CLEARLY MARKED “APPLICATION FOR REGISTRATION ONTO THE UMDONI SERVICES DATABASE” must be placed in the Umdoni Municipality Tender Box, at the corner of Williamson and Airth Streets, Scottburgh. UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ Page 2 SECTION A: Personal Information Registered name of business: _______________________________________________ “Trading as” name of business: _______________________________________________________________________ (Contracts/Orders/Cheques will be issued in this name and invoices must reflect it) Title (Prof. / Dr / Mr / Mrs / Ms) and Surname: _______________________________________________________________________ (If one-man concern) Physical address of business: ________________________________________________________________________ Building, Street name and number: ________________________________________________________________________ Suburb: ______________________City: _______________________________________ Code: _____________ Municipal Area: ________________________________________ Postal address of business: (This is the address to which an Invitation to Tender / enquiry and orders / contracts must be sent to) ________________________________________________________________________ City/Town: _______________________ Code: __________________________________ Telephone numbers of business: _____________________________________________ Alternative number of business: Code: __________Number: _______________________ Fax number: Code: __________Number: _______________________ (Used by Umdoni Municipality for electronic faxing of Request for Quotations, Contracts and Purchase orders) Is this a dedicated fax number? Y N Business e-mail: ________________________________________________________________________ Preferred method of communication: Fax Telephone E Mail Your own business contact person/sales representative name and telephone number: ___________________________________Tel: _________________________________ UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ Page 3 SECTION B: Business Details Business Registration number (if applicable) ______________________________________________________________ (In case of one-man concern, please furnish identity number plus copy of identity documents) Physical Address of Head office:_____________________________________ _______________________________________________________________ Income Tax number of business: _______________________________________________________________ Personal Income tax number: (if a one man concern) _______________________________________________________________ VAT Registration number: (if applicable) _______________________________________________________________ CIDB Grade/s and CRS NO: _______________________________________________________________ Property Rates account number: _______________________________________________________________ District Levy account number: _______________________________________________________________ Name of Banking Institution: _______________________________________________________________ Name under which account is operated________________________________________________________ Banking account number: _______________________________________________________________ Type of Account: _______________________________________________________________ Branch: _______________________________________________________________ Branch code: ____________________________________________________ Previous name of business (if applicable) _______________________________________________________________ UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ SUPPLIER’S EXPERIENCE IN RELATION TO SECTION C No Work discreption Period and value Client contact number , name UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ Page 4 List of Directors / Owners / Partners /Members: (Attach your own list if the space provided is inadequate) Name Position %Shareholding Identity Number Nationality Race Blk. Col. Ind. Disabled Wht. Gender UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ Page 5 SECTION C: Business Classification 1) Please indicate (x) the operations performed by your business, as classified below. 2) If there is not a classification for your business reflected below, please complete the blank section provided Motor Trade A1 Spares & Parts B1 Financial Services Construction only CIDB / NHBRC registered contractors Civil engineering (CE) A2 Auto Electrical B2 Architects General Building works (GB) A3 Brakes and Clutch A4 Transmissions A5 Panel Beaters A6 Tyres A7 Batteries A8 Oil & Lubricants A9 Windscreens A10 Corporate Vehicle Services A11 Engine Overalls B3 Legal services B5 Real Estate B4 Land Surveyor B6 Medical Practitioners B7 Project Managers B8 Quantity Surveyors B9 Town Planners B10 Engineers B11 Consulting Engineers (Civil/Structural) B12 Consulting Engineers (Electrical) B13 Consulting Engineers (Mechanical) B14 Consulting Engineers (Multidisciplinary) B15 Consulting Engineers (Geotechnical) B16 Bookkeepers B17 Insurance Services Other special works SB, SC, SD, SE, SF, SG, SH, SI, SJ , SK, SL, SM, SN, SO, SQ Electrical, Gas & Water Only CIDB registered contractors Electrical engineering works – Building (EB) Electrical Engineering works – Infrustructure (EP) Mechanical Engineering works (ME) Catering, Accommodation & Related Trade A12 Hydraulics A13 Towing Services A14 Upholstery A15 Radiator Repairs A16 General Motor Services A17 Vehicle retail A18 Fuel Supplies Wholesaler Trade, Commercial, Agents, D1 Building Materials D2 Cleaning Supplies D3 Clothing/Printing X Business & Finance Services X F1Food supplies F2 Office Furniture F3Carpet Cleaning D4 Office Supplies& Stationery F4 Catering/vending D5 Industrial Equipment F5 Cleaning Services D6 Workshop Equipment F6 Interior Decorating D7 Fire Protection Equipment F7 Laundry Services D8 Locksmith Services D9Printing/Photography/Graphic Design D10 Air conditioning Systems Page 6 X UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ Transport, Storage & Communication Services G1Advertising /Communication Services G2 Courier Services Community, Social & Personal Services H1Educational Services G3 Travel Agencies H3 Health care Services G4 Computer Supplies/Servicing G5Computers Equipment& Software G6 Personnel Services H4 Municipal Services H2 Horticultural Services H5 Pest removal Services H6 Site / Verge Cleaning H7 Security & Access Control Business not classified. Sector Service Comments SECTION D SMME Information The following Table must be completed in order to establish whether a business can be classified as an SMME in terms of the National Small Business Act 102 of 1996. Indicate the Sector by ticking the appropriate Block in Column 1 and then tick the corresponding Information Blocks in Columns 2, 3, 4 and 5. UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ Page 7 COLUMN 1 COLUMN 2 COLUMN 3 COLUMN 4 COLUMN 5 Sector or subsectors In accordance with the Standard Industrial Council Size of class Total full time equivalent of paid employees Total annual turnover Total gross asset value(fixed property excluded) 1 Agriculture 2 Mining & Quarrying 3 Manufacturing 4 Electricity, Gas & Water Medium Small Very Small Micro Medium Small Very Small Micro Medium Small Very Small Micro Medium 100 50 10 5 200 50 20 5 200 50 20 5 200 Small Very small Micro Medium Small Very Small Micro Medium 50 20 5 200 50 20 5 200 Small Very Small Micro Medium 50 20 5 200 Small Very Small Micro Medium 50 20 5 200 Small Very Small Micro Medium 50 20 5 200 Small Very Small Micro Medium 50 20 5 200 Small Very Small Micro Medium 50 20 5 200 Small Very Small Micro 50 20 5 5 Construction 6 Motor Trade, retail and Repair service 7 8 9 10 11 Wholesale trade, Commercial Agents and Allied Services Catering, Accommodation and other trade Transport, Storage & Communications Finance & Business services Community, Social & Personal Services R5m UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ Page 8 SECTION E: SUPPLIER PROFILE In order for Umdoni Municipality to establish a Profile of its Suppliers, please complete the following: Commercial: Name 3 commercial references/referees of previous projects and provide their name(s) and telephone number(s): Company Contact person Contact number Financial: Are there any pending legal proceedings or previous judgments against your business or has your business ever been declared bankrupt? (Y/N)_____If yes, please elaborate: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Technical: Is your business a permit holder under the SABS mark scheme? (Y/N): ______________ If yes, indicate product(s) for which permits are held, including permit numbers: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Are you working to National or International Standards? (Y/N)_____If yes, indicate products and to which standards: ________________________________________________________________________ ________________________________________________________________________ Quality: Does your business operate a Quality Management System covering the product/service applying for? (Y/N) _______Please elaborate: ________________________________________________________________________ ________________________________________________________________________ Safety: Does your business have an Occupational Health and Safety Policy complying with the Occupational Health and Safety Act (OHSA)? (Y/N)______________________________ Commissioner of Occupational Injuries and Diseases Act (COID) Registration number: ______________________________________________________ Environmental: Do you have an Environmental Policy in place? (Y/N) ____________________________ Does your facility routinely work with any hazardous substances? (Y/N)______________ Page 9 UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ Human Resources: Employment Equity Status: ________________________________________________________________________ Male Female Total All Blk. Indi. Col. Wht. Blk. Indi. Col. Wht. Employment Equity plan Employment Equity achieved ________________________________________________________________________ ________________________________________________________________________ Facilities, Plant & Equipment, Etc: Please indicate the value of the following, based on the latest financial statements: ________________________________________________________________________ Total Assets at Book Value Number of Vehicles Stock on Hand Quantity of Goods Produced Annually Total Current Assets Total Current Liabilities UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ Page 10 SECTION F: DECLARATION DECLARATION AFFIDAVIT FOR TARGETED ENTERPRISE STATUS I/WE, THE UNDERSIGNED, WARRANTS THAT I AM/WE ARE DULY AUTHORISED TO DO SO ON BEHALF OF THE ENTERPRISE, CERTIFIES THAT THE INFORMATION SUPPLIED IN TERMS OF THIS DOCUMENT WITH ADDITIONAL INFORMATION IS CORRECT AND ACCURATE AND ACKNOWLEDGES THAT: 1. The enterprise complies with all requirements for recognition as a Black / Priority Population Group / Black Business Enterprise / Priority Business Enterprise / Woman Business Enterprise / Disabled Person Enterprise / SMME (Delete as applicable) as defined, and; 2. The contents of this Affidavit are within my personal knowledge, and save where stated otherwise are to the best of my belief both true and correct. 3. The enterprise will be required to furnish documentary proof if requested to do so. 4. If the information supplied is found to be incorrect then the Umdoni Municipality in addition to any remedies, it may have; may: i ii Recover from the Enterprise all costs, losses or damages incurred or sustained by the Municipality as a result of the award of any business, and/or Take any other action as may be deemed necessary. Signature ........................................................................................................................................................................................ Name... ........................................................................................................................................................................................... I.D Number .................................................................................................................................................................................... Duly authorised to sign on behalf of: ……....................................................................................................................................... Address ........................................................................................................................................................................................... ................................................................................................................................................................................................ ................................................................................................................................................................................................ Telephone ....................................................................................................................................................................................... SECTION F: SWORN AFFIDAVIT Signed and sworn to before me at ........................................................................................................... on this the ..........................day of .............................................by the Deponent, who has acknowledged that he/she knows and understands the contents of this document, that it is true and correct to the best of his/her knowledge and that he/she has no objection to taking the prescribed oath, and that the prescribed oath will be binding on his/her conscience. Commissioner of Oaths ................................................................................................................................................................ NOTE: Both the Deponent and the Commissioner of Oaths must initial all pages of this Application form. UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ UMDONI MUNICIPALITY TOGETHER BUILDING UNITY – SIYAKHISANA – TESAME BOU ONS EENHEID Postal Address: PO Box 12 Scottburgh 4180 Physical Address: Cnr Airth & Williamson Street Scottburgh 4180 Tel: 039 - 9761202 Fax: 039 - 9760017 DECLARATION OF INTEREST 1. No bid will be accepted from person in the services of the state*. 2. Any person, having a kinship with persons in the service of the state, including a blood relationship, may make an offer or offers in terms of this invitation to bid. In view of possible allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons connected with or related to person in service of the state, it is required that the bidder or their authorized representative declare their position in relation to the evaluating or 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 and submitted with the bid 3.1 Full name:………………………………………………………………………………………… 3.2 Identity Number:………………………………………………………………………………….. 3.3 Company Registrtion Number:………………………………………………………………….. 3.4 Tax Registration Number:……………………………………………………………………….. 3.5 VAT Registration Number:……………………………………………………………………….. 3.6 Are you presently in the service of the state YES / NO 3.6.1 If so, please furnish particulars: ………………………………………………………………………………………………. ……………………………………………………………………………………………….. 3.7 Have you been in the service in the service of the state For the past twelve months? YES /NO 3.7.1If so, please furnish particulars; ……………………………………………………………………………………… ……………………………………………………………………………………… *MSCM Regulations “in the service of the state” means to be: • Any Municipal council • Any provincial legislature; or • 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 municipal or municipal entity (d) an employee of any national or provincial department, national or provincial public entity or constitutional institution with the meaning of the Public Finance Manangement Act, (Act No.1 of 1999) (e) a member of the accounting authority of any national or provincial public entity; or (f) an employee of parliament or a provincial legislature UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ 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 or adjudication of this bid? YES / NO 3.8.1 If so, furnish particulars; ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………. 3.9Are you, aware of any relationship (family, friend, other) between a bidder and any persons in the service of the state who may be involved with the evaluation and or adjudication of this bid? YES / NO 3.9.1 If so, furnish particulars; ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………….. 3.10 Are any of the company’s Directors, Managers, Principle Shareholders or Stakeholders in the service of the state? YES / NO 3.10.1 If so, furnish particulars; ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… …………………………………………………………………………………………………… 3.11Are any spouse, child or parent of the company’s Directors, Managers, Principle Shareholders or Stakeholders in the service of the state? YES / NO 3.11.1 If so, furnish particulars; ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… …………………………………………………………………………………………………….. UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ CERTIFICATION I, THE UNDERSIGNED (NAME)…………………………………………………………………………………… CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS CORRECT. I ACCEPT THAT THE STATE MAY ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE. ……………………………………………. Signature ……………………………………………… Date ……………………………………………. Position …………………………………………………. Name of Bidder UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ DECLARATION OF BIDDERS PAST SUPPLY CHAIN MANAGEMENT PRACTICES 1. This Municipal Bidding Document must form part of all bids invited. 2. It serves as a declaration to be used by municipalities and municipal entities in ensuring that when goods and services are being procured, all reasonable steps are taken to combat the abuse of the Supply Chain Management System. 3. The bid of any bidder may e rejected if that bidder, or any of it’s directors have: • Abuse the Municipality’s / Municipal entity’s Supply Chain Management system or committed any improper conduct in relation to such a system; • Been convicted for fraud or corruption during the past five years; • Willfully neglected, reneged on or failed to comply with any government, municipal or other public sector contract during the past five years; or • Been listed in the registrar for Tender Defaulters I terms of section29 of the Prevention and Combating of Corrupt Activities Act (No.12 of 2004). 4. In order to give effect to the above, the following questionnaire must be completed and submitted with the bid. ITEM 4.1 4.1.1 4.2 4.2.1 4.3 4.3.1 4.4 4.4.1 4.5 4.5.1 QUESTION Is the bidder or any of it’s directors listed on the National Treasury’s database as a company or person prohibited from doing business with the public sector? (Companies or persons who are listed on this database were informed in writing of this restriction by the National Treasury after the audi alteram patem rule was applied). If so, furnish particulars: ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… …………………………………………………………………………………. Is the bidder or any of its directors listed on the Register for Tender Defaulters in terms of section 29 of the Prevention and Combating of Corrupt Activities (Act No. 12 of 2004)? (To access this Register enter the National Treasury’s website, www.treasury.gov.za, click on the icon “Register for Tender Defaulters” or submit your own written request for a hardcopy of the Register to facsimile number: 012-3265445) If so, furnish particulars: ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………… Was the bidder or any of its directors convicted by a court of law (including a court of law outside the Republic of South Africa) for fraud or corruption during the past five years? If so, furnish particulars; ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… …………………………………………………………………………………… Does the bidder or any of its directors owe any municipal rates and taxes or municipal charges to the municipality / municipal entity, or to any other municipality / municipal entity, that is in arrears for more than 3 months? If so, furnish particulars; ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………… Was any contract between the bidder and the municipality / municipal entity or any other organ of the state terminated during the past five years on account of failure to perform on or comply with the contract? If so, furnish particulars; ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… …………………………………………………………………………………… YES YES NO NO YES NO YES NO YES NO YES NO UMDONI MUNICIPALITY Supplier Information Form ________________________________________________________________________________ CERTIFICATION I, THE UNDERSINGED (FULL NAME)…………………………………………………………………… CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS TRUE AND CORRECT. I ACCEPT THAT, IN ADDITION TO CANCELLATION OF A CONTRACT, ACTION MAY BE TAKEN AGAINST ME SHOULD THIS DECLARATION PROVE TO BA FALSE. ………………………………………………….. Signature …………………………………………………… Date ……………………………………………….. Position …………………………………………………… Name of Bidder
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