Ugu Municipality Database Form – Fill Out and Use This PDF

Attached is a Supplier application form to be completed, thus enabling your business to be registered on Ugu District Municipality‟s supplier database, in respect of business

classifications alluded to in Section C of the application form.

COPIES OF THE FOLLOWING CERTIFIED DOCUMENTS MUST BE FURNISHED TOGETHER WITH YOUR APPLICATION:

1.Business Registration Documents

2.Identity documents of directors/owners/members/ shareholders

3.Most recently approved Annual Financial Statements

4.Value Added Tax (VAT) Registration Certificate

5.Tax Clearance Certificate

6.Compensation of Occupational Injuries and Diseases (COID) Registration Certificate

7.Copy of resolutions (if applicable)

8.Company Profile

9.Certificate of acceptance for caterers – Obtained from Environmental Health

10.All relevant registration certificate pertaining to your business, incl. but not limited to

NHBRC Registration

CIDB Registration Certificate

SETA Registration

SAQA pertaining to business sector

Trade test certificates

SOB Registration

Membership certificates for professional services

11.A cancelled cheque or stamped letter from the bank confirming banking details.

Completed Supplier Application Forms, CLEARLY MARKED “APPLICATION FOR REGISTRATION ONTO THE UGU SUPPLIER DATABASE” must be submitted to Procurement, 28 Connor Street, Port Shepstone

ALL SUPPLIER INFORMATION WILL BE TREATED STRICTLY CONFIDENTIAL

SECTION A: Contact details

„Trading as‟ name of business:	____________________________________________
(Contracts/Orders/Cheques will be issued in this name and invoices must reflect it)
Registered name of business:	___________________________________________

Physical address of business:

Building / complex name: ____________________________________________________

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)

Postnet suite number ________________________________________________________

P O Box __________________________________________________________________

_____________________________City/Town: _______________________ Code: _______

Telephone numbers of business: Code: __________Number: ________________________

Alternative number of business: Code: __________Number: _________________________

Sales person fax number: Code: __________Number: ______________________________

Alternative person fax number: Code: __________Number: __________________________

(Used by Ugu District Municipality for electronic faxing of Request for Quotations, Contracts and Purchase orders)

Is this a dedicated fax number? (y/n) ____________________________________________

Business e-mail: ____________________________________________________________

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

___________________________________Tel: ___________________________________

SECTION B: Business Details

Business Registration number _________________________________________________

(in case of a sole proprietor, please furnish identity number plus copy of identity documents) Income Tax number of business: ______________________________________________

VAT Registration number:	______________________________________________
CIDB registration number:	______________________________________________
Name of Banking Institution:	______________________________________________
Name of account	______________________________________________

Banking account number: ____________________________________________________

Branch: __________________________________________________________________

Branch code: ______________________________________________________________

Please indicate (x) the geographical areas where your business is located:

Gauteng		Kwa-Zulu Natal
Western Cape		Mpumalanga
Free State		Eastern Cape
North West		Northern Cape
Northern Province

Are you locally based, i.e. within Ugu District Municipality yes/no ____________

Previous name of business (if applicable)

_________________________________________________________________

_________________________________________________________________

BUSINESS OWNERSHIP

List of directors / owners / partners /members: (Attach your own list if the space provided is inadequate)

1. Name: ___________________________________________________________

Position: _________________________________________________________

%Shareholding/Members Interest _______________________________________

Identity Number____________________________________________________

Nationality________________________________________________________

Gender:__________________________________________________________

2.Name:____________________________________________________________

Position: _________________________________________________________

%Shareholding/Members Interest ________________________________________

Identity Number____________________________________________________

Nationality________________________________________________________

Gender:__________________________________________________________

3.Name: ___________________________________________________________

Position: _________________________________________________________

%Shareholding/Members Interest _____________________________________

Identity Number____________________________________________________

Nationality________________________________________________________

Gender:__________________________________________________________

DECLARATION OF INTEREST

1No bid will be accepted from persons in the service of the state.

2Any 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 persons in service of the state, it is required that the bidder or their authorised representative declare their position in relation to the evaluating/adjudicating authority and/or take an oath declaring his/her interest.

3In order to give effect to the above, the following questionnaire must be completed and submitted with the bid.

3.1Full Name: ……………….……………………………………………………………………….

3.2Identity Number: .………….………………………………………………………………………

3.3Company Registration Number: …………………………………………………………………

3.4Tax Reference Number:……………………………………………………………..……………

3.5VAT Registration Number: ……………………………………………………………………….

3.6Are you presently in the service of the state? ……………………………………..YES / NO 3.6.1 If so, furnish particulars……………………………………………………………….

………..………………………………………………………………………………………….

3.7Have you been in the service of the state for the past twelve months? ……….YES / NO 3.7.1 If so, furnish particulars……………………………………………………………….

…………………………………………………………………………………………………...

3.8Do you, have any relationship (family, friend, other) with persons in the service of the

state who may be involved in the evaluation and / adjudication of this bid? …..YES?NO

3.8.1If 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

3.9.1If so, furnish particulars……………………………………………………………….

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

3.10Are any of the company‟s directors, managers, principal shareholders or stakeholders in service of the state?..................................…………………………………….YES / NO

3.10.1If so, furnish particulars……………………………………………………………….

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

3.11 Is any spouse, child or parent of the company‟s directors, managers, principal

shareholders or stakeholders in service of the state?

YES / NO

3.11.1If so, furnish particulars…………...…..………………………………………………………

……………………………………..……………………………………………………………

BUSINESS MANAGEMENT

List of management: Please indicate level of participation in the business (Attach your own list if the space provided is inadequate)

1.Name: ___________________________________________________________

Position: _________________________________________________________

Identity Number: ___________________________________________________

Nationality: ________________________________________________________

Gender: __________________________________________________________

2.Name:____________________________________________________________

Position: _________________________________________________________

Identity Number____________________________________________________

Nationality________________________________________________________

Gender: _________________________________________________________

3.Name: ___________________________________________________________

Position: _________________________________________________________

Identity Number_____________________________________________________

Nationality_________________________________________________________

Gender: __________________________________________________________

SECTION C: Business Classification

1)Please indicate (x) in the business classification area applicable to your business:

Professional services

Auxiliary services

Material supply

Construction

Vehicles services

Workshop services

Corporate Services

Other specify

If there are operations performed by your business, not reflected in Section C (3) below, please complete this section [i.e. C (2)].

2)Nature of Operations:

Please indicate (X) nature of business operations

	Vehicle Services		Construction				Material supply				Auxiliary services
											Advertising/communicatio
	Panel beating		Concrete works				Building materials				n
	Auto Electrical		Pre-cast concrete manuf.				Cleaning supplies				Carpet cleaning
	Brakes and Clutch		Demolition				Safety Clothing				Cleaning services
	Transmissions		Electrical contracts				Office furniture				Catering/vending
	Tyres		Evacuation systems				Office supplies& stationery				Catering equipment hire
	Batteries		Fencing				Fire protection equipment				Computer hardware
	Mechanical work		General building work				Oil & Lubricants				Computer software
	Windscreens		Glazing				Bulk gases				Vehicle hire
	Communicative		Goods transport hire				Chemicals				Training
	Engine overhauls		Earthworks				Fuel				Arts and culture
			Metalwork	&	burglar
	Towing Services		guards				Hardware supplies				Horticultural services
	Upholstery		Sheeting				Workshop tools				Garden Maintenance
	Radiator repairs		Industrial Painting				Food supplies				Site cleaning
			Decorative painting				Plumbing material				Landscaping
	Workshop Services		Paving				Pipe& irrigation supplies				Interior decorating
	Electrical component supplies		Plumbing				Hydraulics & Pneumatics				Waste management
	Electrical motor repairs		Pumping installation				Vehicle Spares				Laundry services
	Transformer services		Road works				Pumps / spares				Locksmith services
	Pump repairs		Special contracts				Bolts & nuts				Courier services
							Mechanical	seals	&
	Motor rewinds		Sand and stone				packings				Health care services
	Hydraulic & Pneumatic repairs		Equipment hire				Lifting equipment				Municipal services
							Bearings				Personnel services
	Professional services						Glass specialists				Pest removal services
	Insurance services										Real estate
	Financial services										Travel agencies
	Architects										Security & access control
	Legal services										Air conditioning systems
	Land surveyors										Telemetry
	Medical practitioners										Water Purification
	Project managers
	Quantity surveyors										Corporate services
	Town planners										Corporate Clothing /gifts
	Engineers										Events Management
	Consulting Engineers (Civil/Structural)										Printing/graphic design
	Consulting Engineers (Electrical)										Sound equipment
	Consulting Engineers (Mechanical)
	Consulting Engineers
	(Multidisciplinary)
	Consulting Engineers (Geotechnical)
	Social development consultants

SECTION D: SUPPLIER PROFILE

In order for Ugu District Municipality to establish a profile of its suppliers, please complete the following:

Commercial:

1.Name 3 commercial references/referees of previous projects and provide their name(s) and telephone number(s):

Financial:

1.Are there any pending legal proceedings or previous judgements against your business or has your business ever been declared bankrupt? (y/n)_____If yes, please elaborate:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Technical:

1.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:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

2.Are you working to National or International Standards? (y/n)_____If yes, indicate products and to which standards:

________________________________________________________________________

_________________________________________________________________________

Quality:

1. Does your business operate a Quality Management System covering the product/service applying for? (y/n) _______Please elaborate:

________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

2.Has your Quality Management System been assessed and certified by any National / Internationally recognised accredited body? (y/n)____If yes, please provide copy of certificate.

Safety:

1.Does your business have an Occupational Health and Safety Policy complying with the Occupational Health and Safety Act (OHSA)? (y/n)______________________________

2.Are you registered with Compensation of Occupational Injuries and Diseases Act (COID)? (y/n) ___________ COID registration number: __________________________

Environmental:

1.Do you have an Environmental Policy in place? (y/n) ____________________________

2.Does your facility routinely work with any hazardous substances? (y/n)______________

Human Resources:

1.Briefly state your Affirmative Action (AA) policy: _________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Facilities, plant & equipment:

1.Please give a summary of your plant and facilities: ______________________________

________________________________________________________________________

________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

2.Please give a summary of your equipment: ____________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

SECTION E: DECLARATION

I/WE, THE UNDERSIGNED, WARRANTS THAT I AM/WE ARE DULY AUTHORISED TO DO SO ON BEHALF OF THE ENTERPRISE TO CERTIFY 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 Ugu District 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

iiTake 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.