Supplier Application 2009 New DATABASE FORM A&D; Postal Equipment SF/SG Information

UMDONI MUNICIPALITY

Supplier Information Form

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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

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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?

Business e-mail:

________________________________________________________________________

Preferred method of communication:

Your own business contact person/sales representative name and telephone number:

___________________________________Tel: _________________________________

Y

N

Fax

Telephone

E Mail

UMDONI MUNICIPALITY

Supplier Information Form

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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

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SUPPLIER’S EXPERIENCE IN RELATION TO SECTION C

No

Wor

k discreption

Period and value

Client contact

number , name

UMDONI MUNICIPALITY

Supplier Information Form

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Page 4

List of Directors / Owners / Partners /Members: (Attach your own list if the space provided is inadequate)

Name

Position

%Share

hold

-

ing

Identity Number

Nationality

Race

Disabled

Gender

Blk.

Col.

Ind.

Wht.

UMDONI MUNICIPALITY

Supplier Information Form

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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

X

Business & Finance Services

X

Construction

only CIDB /

NHBRC registered contractors

X

A1 Spares & Parts B1 Financial Services Civil engineering (CE)

A2 Auto Electrical B2 Architects General Building works (GB)

A3 Brakes and Clutch B3 Legal services Other special works

SB, SC, SD, SE, SF, SG, SH, SI,

SJ , SK, SL, SM, SN, SO, SQ

A4 Transmissions B5 Real Estate

A5 Panel Beaters B4 Land Surveyor

A6 Tyres B6 Medical Practitioners

A7 Batteries B7 Project Managers

A8 Oil & Lubricants B8 Quantity Surveyors

A9 Windscreens B9 Town Planners

A10 Corporate Vehicle Services B10 Engineers

A11 Engine Overalls B11 Consulting Engineers

(Civil/Structural)

A12 Hydraulics B12 Consulting Engineers

(Electrical)

A13 Towing Services B13 Consulting Engineers

(Mechanical)

A14 Upholstery B14 Consulting Engineers

(Multidisciplinary)

A15 Radiator Repairs B15 Consulting Engineers

(Geotechnical)

A16 General Motor Services B16 Bookkeepers

A17 Vehicle retail B17 Insurance Services

A18 Fuel Supplies

Wholesaler Trade,

Commercial, Agents,

Electrical, Gas & Water

Only CIDB registered

contractors

Catering, Accommodation &

Related Trade

D1 Building Materials Electrical engineering works –

Building (EB) F1Food supplies

D2 Cleaning Supplies Electrical Engineering works –

Infrustructure (EP) F2 Office Furniture

D3 Clothing/Printing Mechanical Engineering works

(ME) 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

UMDONI MUNICIPALITY

Supplier Information Form

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Transport, Storage &

Communication Services

Community, Social & Personal

Services

G1Advertising /Communication

Services H1Educational Services

G2 Courier Services H2 Horticultural Services

G3 Travel Agencies H3 Health care Services

G4 Computer

Supplies/Servicing H4 Municipal Services

G5Computers Equipment&

Software H5 Pest removal Services

G6 Personnel 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

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Page 7

COLUMN 1

COLUMN 2

COLUMN 3

COLUMN 4

COLUMN 5

Sector or sub

-

sectors

In accordance with

the Standard

Industrial Council

Size of class

Total full

time

equivalent

of paid

employees

T o t a l

a n n u a l

turnover

Total gross

asset

value(fixed

property

excluded)

1 Agriculture Medium 100 R5m

Small 50

Very Small 10

Micro 5

2 Mining & Quarrying Medium 200

Small 50

Very Small 20

Micro 5

3 Manufacturing Medium 200

Small 50

Very Small 20

Micro 5

4 Electricity, Gas &

Water

Medium 200

Small 50

Very small 20

Micro 5

5 Construction Medium 200

Small 50

Very Small 20

Micro 5

6 Motor Trade, retail

and Repair service

Medium 200

Small 50

Very Small 20

Micro 5

7 Wholesale trade,

Commercial Agents

and Allied Services

Medium 200

Small 50

Very Small 20

Micro 5

8 Catering,

Accommodation and

other trade

Medium 200

Small 50

Very Small 20

Micro 5

9 Transport, Storage &

Communications

Medium 200

Small 50

Very Small 20

Micro 5

10 Finance & Business

services

Medium 200

Small 50

Very Small 20

Micro 5

11 Community, Social &

Personal Services

Medium 200

Small 50

Very Small 20

Micro

5

UMDONI MUNICIPALITY

Supplier Information Form

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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

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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

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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 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

ii 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: Physical Address: Tel: 039 - 9761202

PO Box 12 Cnr Airth & Williamson Street Fax: 039 - 9760017

Scottburgh Scottburgh

4180 4180

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

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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

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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

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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

QUESTION

YES

NO

4.1 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

audi alteram patemaudi alteram patem

audi alteram patem rule was applied).

YES NO

4.1.1 If so, furnish particulars:

…………………………………………………………………………………………………………………

………………………………………………………………………………….

4.2 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)

YES NO

4.2.1 If so, furnish particulars:

…………………………………………………………………………………………………………………

…………………………………………………………………………………

4.3 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? YES NO

4.3.1 If so, furnish particulars;

…………………………………………………………………………………………………………………

……………………………………………………………………………………

4.4 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?

YES NO

4.4.1 If so, furnish particulars;

…………………………………………………………………………………………………………………

…………………………………………………………………………………

4.5 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?

YES NO

4.5.1 If so, furnish particulars;

…………………………………………………………………………………………………………………

……………………………………………………………………………………

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

Supplier Application 2009 New DATABASE FORM A&D; Postal Equipment SF/SG Information

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