LUKHANJI DIRECTORATE: FINANCE SUPPLY CHAIN MANAGEMENT UNIT

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1 MUNICIPALITY UMASIPALA MUNISIPALITEIT LUKHANJI DIRECTORATE: FINANCE SUPPLY CHAIN MANAGEMENT UNIT Private Bag X7111 QUEENSTOWN 5320 Telephone: Fax: Website: APPLICATION FOR REGISTRATION ON LUKHANJI MUNICIPALTY S DATABASE OF SERVICE PROVIDERS / SUPPLIERS Please fill in the form as fully as possible and ensure that all the supporting documentation requested is included with your application. Failure to comply will prejudice your application. Please request assistance if you need it to complete your application. Company/ Supplier Name: VAT Registration number: Income tax reference number: Web Address: Address: Telephone Number: Fax Number: Postal & Physical Address: Contact Person: : PREFERED METHOD OF COMMUNICATION: FAX POST (INDICATE WITH A TICK) 1 P a g e

2 BANKING DETAILS I/We hereby request and authorise LUKHANJI LOCAL MUNICIPALITY to pay any amounts that are due to me/us into my/our bank account held at the below mentioned financial institution. This authority will remain in force until such time it is cancelled by me/us giving (30) days written notice by prepaid registered post. Initial and Surname Authorised Signature Date NAME OF BANK: NAME OF BRANCH: BRANCH CODE: NAME OF ACCT HOLDER: (Name under which account is operated) ACCOUNT NUMBER: ACCOUNT TYPE: ACCOUNT SAVINGS ACCOUNT TRANSMISSION ACCOUNT CHEQUE ACCOUNT CURRENT OTHER (PLEASE SPECIFY) OFFICIAL: DETAILS OF BANK NAME: DATE RECEIVED: SIGNATURE: Bank stamp certifying the above bank account details as correct Page 2

3 SERVICES / PRODUCTS OFFERED (list main categories & describe full range in profile) NOTES: Only one application need be submitted per applicant irrespective of how many types of services / goods are offered. This application is in respect of those services and / or goods to be procured by means of the quotation system described in Lukhanji Municipality s Supply Chain Management policy. Where procurement is done by means of the formal bidding procedure described in the Supply Chain Management policy bids will be invited by via media advertisement open to all potential suppliers. In those cases suppliers on the database will not be automatically considered but bids must be submitted on the official tender documents. DETAILS OF REFERENCES FOR WHOM WORK HAS BEEN CARRIED OUT OR TO WHOM GOODS / SERVICES HAVE BEEN DELIVERED TO WITHIN THE PAST 5 YEARS DATE TYPE OF WORK / SERVICE / GOODS FIRM / CONTACT PERSON TELEPHONE NO. 3 P a g e

4 DECLARATION I,, applying on behalf of.. hereby declare that: - I am duly authorized to make this application; - The information submitted in this application and all of the supporting documentation is, to the best of my knowledge, complete and correct; - Neither I nor any of the directors of the firm on whose behalf I am applying have been convicted of fraud or corruption during the past five (5) years; - Neither I nor the firm on whose behalf I am applying is prohibited by the National Treasury or any order of a South African court from doing business with an organ of the state; - Neither I nor the firm on whose behalf I am applying has defaulted on a contract with Lukhanji Municipality during the past five years; - Neither I nor the firm on whose behalf I am applying is insolvent; - Neither I nor the firm on whose behalf I am applying is in arrears with my / our / its Lukhanji Municipality rates or service account; - Neither I nor any director, manager, principal shareholder or stakeholder of the firm on whose behalf I am applying is in the service of the state. I further understand that the inclusion of myself or the firm on whose behalf I am applying on Lukhanji Municipality s database of suppliers does not guarantee or imply that I will obtain an order to supply any goods and/or services to Lukhanji Municipality. I accept that quotations will be obtained from suppliers on the database on a rotational basis. I accept that, in terms of Lukhanji Municipality s Supply Chain Management policy and relevant legislation ruling at the time, preference will be granted to local suppliers, SMMEs, previously disadvantaged individuals and BEE firms when allocating orders for goods and services. I accept that if I, or the firm on whose behalf I am applying, fall(s) into arrears (60 days or longer) with my / our Lukhanji Municipal account, Lukhanji Municipality has the right to remove me / the firm from the database and to summarily cancel any order already placed with me / the firm... (Signature). (Date) ID number of declarer. (Firm s stamp) Page 4

5 DECLARATION OF INTEREST 1. Any legal person, including persons employed by the State, or persons who act on behalf of the State or persons having a kinship with persons employed by the State, including a blood relationship, may make an offer or offers in terms of this bid invitation. In view of possible allegations of favoritism, should the resulting bid, or part thereof, be awarded to persons employed by the State, or to persons who act on behalf of the State, or to persons connected with or related to them, it is required that the bidder or his authorized representative shall declare his position vis-à-vis the evaluating authority and/or take an oath declaring his interest, where The bidder is employed by the State or acts on behalf of the State; and/or The legal person on whose behalf the bid document is signed, has a relationship with persons/a person who are/is involved with the evaluation 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 of the bid In order to give effect to the above, the following questionnaire shall be completed and submitted with the bid. 1.1 Are you or any person connected with the bidder, employed by the State, Lukhanji Municipality *YES/NO If so, state particulars 1.2 Do you, or any person connected with the bidder, have any relationship (family, friend, other) with a person employed in the department concerned, with Lukhanji Municipality or its administration and who may be involved with the evaluation or adjudication of this bid? *YES/NO If so, state the particulars 1.3 Are you, or any person connected with the bidder, aware of any relationship (family, friend, other) between the bidder and any person employed by Lukhanji Municipality or its administration, who may be involved with the evaluation or adjudication of this bid? *YES/NO If so, state particulars Signature of Declarant Bid number: Date Position of Declarant Name of Company: 5 P a g e

6 Signed and affirmed before me at on this Day of year by the dependent who has acknowledged that he/she knows and understands, the contents of this document, and he/she has acknowledged that he/she regards the affirmation to be binding on his/her conscience. Commissioner of Oaths Full Name Capacity Business address NOTE: Both the dependent and the Commissioner of Oath must initial all pages of the application form DECLARATION OF BIDDER'S PAST SUPPLY CHAIN MANAGEMENT PRACTICES 1 This declaration will be used by institutions 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. 2 The bid of any bidder may be disregarded if that bidder, or any of its directors have: abused the state or Lukhanji Municipal supply chain management system; committed fraud or any other improper conduct in relation to such system; or failed to perform on any previous contract. 3 In order to give effect to the above, the following questionnaire must be completed and submitted with the bid. Item Question Yes No 3.1 Is the bidder or any of its directors listed on the National Treasury s database as companies or persons prohibited from doing business with the public sector or state? If so, furnish particulars: Yes No 3.2 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)? If so, furnish particulars: Yes No 3.3 Was the bidder or any of its directors convicted by a court of law (including a court outside of the Republic of South Africa) for fraud or corruption during the past five years? If so, furnish particulars: 3.4 Was any contract between the bidder and any organ of 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 Page 6

7 CERTIFICATION I, THE UNDERSIGNED (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 BE FALSE. Signature Date: Position Name of bidder: Points awarded for B-BBEE Status Level of Contribution In terms of Regulation 5 (2) and 6 (2) of the Preferential Procurement Regulations, preference points must be awarded to a bidder for attaining the B-BBEE status level of contribution in accordance with the table below: B-BBEE Status Level of Contributor Number of points (90/10 system) Number of points (80/20 system) Non-compliant contributor 0 0 Bidders who qualify as EMEs in terms of the B-BBEE Act must submit a certificate issued by an Accounting Officer as contemplated in the CCA or a Verification Agency accredited by SANAS or a Registered Auditor. Registered auditors do not need to meet the prerequisite for IRBA s approval for the purpose of conducting verification and issuing EMEs with B-BBEE Status Level Certificates. Bidders other than EMEs must submit their original and valid B-BBEE status level verification certificate or a certified copy thereof, substantiating their B-BBEE rating issued by a Registered Auditor approved by IRBA or a Verification Agency accredited by SANAS. A trust, consortium or joint venture, will qualify for points for their B-BBEE status level as a legal entity, provided that the entity submits their B-BBEE status level certificate. A trust, consortium or joint venture will qualify for points for their B-BBEE status level as an 7 P a g e

8 unincorporated entity, provided that the entity submits their consolidated B-BBEE scorecard as if they were a group structure and that such a consolidated B-BBEE scorecard is prepared for every separate bid. Tertiary institutions and public entities will be required to submit their B-BBEE status level certificates in terms of the specialized scorecard contained in the B-BBEE Codes of Good Practice. A person will not be awarded points for B-BBEE status level if it is indicated in the bid documents that such a bidder intends sub-contracting more than 25% of the value of the contract to any other enterprise that does not qualify for at least the points that such a bidder qualifies for, unless the intended subcontractor is an EME that has the capability and ability to execute the sub-contract. A person awarded a contract may not sub-contract more than 25% of the value of the contract to any other enterprise that does not have an equal or higher B-BBEE status level than the person concerned, unless the contract is sub-contracted to an EME that has the capability and ability to execute the sub-contract. BID DECLARATION Bidders who claim points in respect of B-BBEE Status Level of Contribution must complete the following: B-BBEE STATUS LEVEL OF CONTRIBUTION CLAIMED IN TERMS OF PARAGRAPHS TABLE ABOVE 7.1 B-BBEE Status Level of Contribution: = (Maximum of 20 points) (Points claimed in respect of paragraph 7.1 must be in accordance with the table reflected in paragraph below and must be substantiated by means of a B-BBEE certificate issued by a Verification Agency accredited by SANAS or a Registered Auditor approved by IRBA or an Accounting Officer as contemplated in the CCA). SUB-CONTRACTING Will any portion of the contract be sub-contracted? YES / NO (delete which is not applicable) If yes, indicate: (i) what percentage of the contract will be subcontracted?.... % (ii) the name of the sub-contractor?.. (iii) the B-BBEE status level of the sub-contractor?.. (iv) whether the sub-contractor is an EME? YES / NO (delete which is not applicable) Broad-Based Black Economic Empowerment B-BBEE Status: Please read notes below very carefully before completing. Page 8

9 Instructions and Definitions: Legislation: MFMA states that the accounting officer of a municipality must ensure that the municipality has and maintains an appropriate procurement and provisioning system which is fair, equitable, transparent, competitive and cost-effective. Terminology: Commodities: The commodities the company wishes to be registered for as a supplier to the department. Trade Names: The trade names that the company owns or distributes, which you wish to be registered for as a supplier to the department. Owned: Having all the customary elements of ownership, including the right of decision making and sharing all the risks and profits commensurate with the degree of ownership interests as demonstrated by an examination rather than the form of ownership arrangements. B-BBEE Status Level of Contribution: means broad-based black economic empowerment as defined in section 1 of the Broad-Based Black Economic Empowerment Act B-BBEE Status Level of Contribution: means the B-BBEE status received by a measured entity based on its overall performance using the relevant scorecard contained in the Codes of Good Practice on Black Economic Empowerment, issued in terms of section 9(1) of the Broad-Based Black Economic Empowerment Act; EME: means any enterprise with annual total revenue of R5 million or less. Declaration of any conflict of interest: I/we the undersigned acknowledge(s) that: The information furnished is true and correct. The B-BBEE claimed is in accordance with the new Preferential Procurement Policy Framework Act 2000 (PPPFA). Any conflict of interest will be declared in the comment space below. SIGNATURE OF THE OWNER OR AUTHORISED REPRESENTATIVE DATE Comments / Notes 9 P a g e

10 Documents/Attachments Original Tax Clearance Certificate Company Registration Certificate Most recent municipal accounts for your business location or your personal Residence i.e. rates, water, refuse, electricity (if applicable) and levy registration confirmation letter. Banking details certified by bank (page2) Letter from your bank confirming your banking with them /Cancelled cheque Company Profile Original Copy or Certified copy of BBBEE Certificate if any Certified Copies of Identity document (Owner/s) Page 10

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