Zululand DISTRICT MUNICIPALITY UMKHANDLU WESIFUNDA

Transcription

1 Zululand DISTRICT MUNICIPALITY UMKHANDLU WESIFUNDA SUPPLIERS DATABASE REGISTRATION FORM DELIVER TO: PROCUREMENT OFFICER QUEEN SILOMO CENTRE ZULULAND DISTRICT MUNICIPALITY OFFICES PRINCESS MKABAYI STREET ULUNDI OR POST TO: THE PROCUREMENT OFFICER ZULULAND DISTRICT MUNICIPALITY PRIVATE BAG X 76 ULUNDI 3838 ALL ENQUIRIES TO BE DIRECTED TO: THE PROCUREMENT OFFICER TELEPHONE: FAX NUMBER: /91 FOR OFFICE USE Supplier Name: ZDM Registration Number: ZDMDB Captured By: Date: Approved By: Date:

2 SECTION A: INSTRUCTIONS INTRODUCTION The ZDMDB form was specifically designed to provide for the registration of suppliers on the Zululand District Municipality s suppliers database. In order to ensure that suppliers are considered legitimate, it is imperative that the following guidelines are adhered to. GUIDELINES Applicants must complete pages 2 to 16, where applicable. Failure by an applicant to provide ALL the prescribed information and documents required will result in nonregistration. If the information required is not applicable to your business; clearly insert the symbols N/A in the appropriate space. All mandatory fields marked by two asterisks** are to be filled in. If the space provided is left blank and or mandatory fields are not filled in, it will be regarded as information that is still outstanding and you WILL NOT be registered. Only black ink is to be used when filling in the form. 1. Applicants are advised that only ORIGINAL ZDMDB form or PHOTOSTAT copies thereof will be processed. Any document that has been retyped or redrafted will be disregarded and returned to the applicant. 2. It is imperative that only supporting documents with an ORIGINAL signature be submitted. 3. All signatures to the document must be commissioned by an authorized Commissioner of Oaths. Failure to do so will result in the applicant not qualifying for registration. 4. A supplier registered on the Suppliers Database MUST notify the Supply Chain Management Office of any changes to information provided in the initial ZDMDB form, as captured onto the Suppliers Database. Failure to so may result in such a supplier being removed from the Suppliers Database and/or the cancellation of contracts awarded to the supplier, on the basis of misrepresentation. 5. Suppliers providing information incorrectly or fraudulently in their ZDMDB form will be disqualified from bidding and removed from the Suppliers Database, in addition to any other action the Province may institute against such a supplier. Furthermore, in the event of the province being prejudiced financially, it reserves the right to take legal action against the supplier. 6. For definitions of terminology used in this document, please refer to the definitions set out in Treasury Regulation 16A and the Zululand District Municipality s Supply Chain Management Policy Framework, located on the Zululand District Municipality s website, 7. Any alterations made by the supplier to its own information inserted on this document, must be initiated by the supplier. The use of correcting fluid is prohibited and the use thereof will lead to non-registration of the applicant business/supplier. 8. Reminder letters will be issued by the Zululand District Municipality to suppliers to update their information. It remains the responsibility of the supplier to ensure that their information is updated in the Suppliers Database, therefore if a reminder letter is not received, the supplier must follow up with Zululand District Municipality. 9. Electronic forms are available on the website: Select Supplier Database. 2

3 SECTION B: COMPANY INFORMATION 1. Business particulars** The following information must be filled in by the applicant. Failure to submit ALL the required information may lead to non-registration of the applicant s business PLEASE USE BLOCK LETTERS. Name of business as registered with Registrar of Companies Trading as Holding company Registration number of Company/CC/Trust/Fund no. Business Postal address Business Physical address Telephone number Fax number Cellular phone number address Website address Preferred language Contact person (Full Name & Surname) Physical location of Head Office (if applicable) 3

4 2. Financial information ** Name of bank Name of account holder Type of bank account Branch name Bank branch number (at least six numbers) Bank account number NB: A certified copy of latest bank statement or original cancelled cheque or Annexure A to be completed and confirmed by your bank. UIF number Compensation Commissioner Registration number Income Tax reference number Construction Industry Development Board Registration number (CIDB) PAYE number VAT registration number Tax clearance certificate issue date Tax clearance certificate expiry date Financial year-end NB: A certified Tax Clearance Certificate must be attached. 3. Indicate the value of the below stated based on the latest financial statements** Total fixed at book value (e.g land, buildings, plants, equipment) Vehicles at book value Number of vehicles Average stock on hand Cost of goods produced annually Quantity produced annually Units of measure (e.g. tons, kilolitres) Total current assets (e.g stock, debtors,cash) Total current liabilities (e.g creditors, bank overdraft) 4

5 4. Municipalities** Please clearly indicate, with an X, the District Municipality/s where your business operates. ethekwini Municipality (DC 20) Amajuba Municipality (DC 25) Ugu Municipality (DC 21) Zululand Municipality (DC 26) Umgungundlovu Municipality (DC 22) Umkhanyakude Municipality (DC 27) Uthukela Municipality (DC23) Uthungulu Municipality (DC 28) Umzinyathi Municipality (DC 24) Ilembe Municipality (DC 29) Sisonke Municipality (DC 47) 5. Previous business information (if applicable) Did you business exist under a different name previously? If yes what was the previous business name? Reason for name change: 6. Business Sector** (Please see pages 8-9 for details Please indicate the sector applicable to your business. Core Business Area Agriculture Mining & Quarrying Manufacture Electricity, Gas & Water Construction Retail, Motor Trade & Repair Wholesale Trade & Commercial Catering, Accommodation, Other Transport & Storage Finance & Business Services Community, Social & Personal 5

6 7. Previous experience (if applicable)** List the last three (3) contracts awarded to you (the supplier) or other previous experience related to your core business. CONTRACT 1 Employer / Department Contact person Initials Telephone number Was the project completed successfully? What year was the project initiated? What was the contact value? CONTRACT 2 Employer / Department Contact person Initials Telephone number Was the project completed successfully What year was the project initiated? What was the contact value? CONTRACT 3 Employer / Department Contact person Initials Telephone number Was the project completed successfully? What year was the project initiated? What was the contact value? 6

7 SECTION C: CLASSIFICATION OF BUSINESS 1. Type of business** Please mark with an x the block applicable to your business or firm AND attach the relevant certified copy A. Public Company LTD Certified copy of certificate of incorporation (CM1) Private Company (PTY) LTD Close Corporation CC Incorporated Sole proprietor Certified copy of certificate of incorporation ( CM1) Certified copy of CK 1 document and CK 2 if applicable Certified copy of certificate of incorporation (CM1&CM29 Certified copy of Identity document Partnership Certified copy of partnership agreement Trust Certified copy of trust document Co-operative Welfare organization Certified copy of proof of registration with Directors Co. Certified copy of constitution Total Gross Asset value (fixed property excluded) Annual turnover Number of employees 7

8 2. Products & Services** In order to assist with the classification of suppliers, please indicate the industrial sector related to the goods/services that you supply. (Only a maximum of FOUR industrial sectors will be considered.) If the supplier selects more than FOUR (4) industrial sectors, only the first FOUR will be considered.) Please mark with an X the appropriate block to clearly indicate the industrial sector related to the goods and services that you supply. Construction Airconditioning Systems Electrical Contracts Plumbing Alarm/Security Systems/Access Control Evacuation Systems Precast Concrete Manufacture Autoclavos Fencing Pumping Installations Automatic Hanger Doors General Building Work Signage & Road Marking Automatic Sliding Doors Glazing Cleaning & Roadworks Automatic Sprinkle Fire Protection Systems Hauling/Heavy Equipment /Transport Waterproofing & Roofing Brickwork/Masonry Hot Water Installations Reticulations / Sewerage Installations Cabinet/Furniture Making Incinerators Ancilliary &Installations Steam Equipment Carpeting/Tiling/Floor Covering Ceilings, Partitioning and Shopfitting Cladding Contracts Cooking & Related Systems Compressed Air Installions Painting Concrete works Paving Earthworks / Landscaping Erection & Steel Fabrication Escalator Equipment & Lift Stormwater draining Contracts Mechanical reticulations / Water installations Burglar Bars & Metalwork ( Specify) Other Demolition Plastering Services Accommodation Food & Beverage Personnel Services Advertising/Public Relations Funeral Services Pest Removal Services Auto Repairs & Services Florist Performance Management Auto Electrical and Hydraulic Repairs Garden Services Printing/Photography/Graphic Design Bookkeepers Handyman Promotional Materials Carpet Cleaning Horticultural Services Publishing Catering/Vending/Food Supply HV Fault Finding. Jointing & Terminations Real Estate Cleaning Services Insurance/Employee Benefits Radio Publicity/TV Publicity Computer Supplies/Services Interior/Industrial Design Road Maintenance Corporate Gifts/Corporate Clothing IT Maintenance Recruitment Agencies Copywriting IT Management Safety & Security Services Courier Services IT Networking Security & Access Control Servicing HV & LV Cleaning Equipment/Materials IT Programming Switchgear/Transformers Diesel & Petrol Engines Laundry Service/Dry Cleaning Site Cleaning Debt Collection Locksmith Services Solid Waste Disposal Distribution Media Liaison Telecommunications Digging of Graves Mailing/Courier Services Travel Agencies Educational Services Medical/Ambulance/Health Care Timber Contractor Entertainment Municipal Services Telephone and Data Line Maintenance Fire Extinguishers & Refills Medical Equipment/Instruments Training & Development Fire Hydrants Office Maintenance Wind Socks for the Aerodrome Other (Specify) 8

9 Professional Services Accountants/Financial Advisory Services EDMS Consultants Pre-Employment Assessment Consultants Architects EAP Consultants Project Managers Attorneys/Legal Services Economists Quantity Surveyors Archival Services Consultants Industrial Relations Consultants Statisticians Business Information Management Job Descritption Consultants Teachers Consulting Engineers (Geotechnical) Land Surveyors Town Planners Consulting Engineers (Civil/Structure) Legal Compliance Consultants Training Providers Consulting Engineers (Electrical) Medical Practioners Translation Services Consulting Engineers (Mechanical) OHS Consultants Other (Specify) Consulting Engineers (Multidisciplinary) Organisation Development Consultants Contractors Wholesalers/Traders Pharmacists Automotive Parts Fuel Supplies Recreational Supplies Air Polution Measuring Equipment Furniture Refrigeration & Air Conditioning Books Fencing Refuse Bulk Containers Fire Fighting Equipment and Building Materials/Hardware Consumables Protective Clothing/Uniforms Batteries Food for Game Animals Radio/Radio Equipment Cleaning Supplies/Chemicals/Pesticides Generating Sets Supply plants, flowers and seeds Clothing Health Safety and Environmental Suppliers Toilet Paper Wrapped/Unwrapped Computer Equipment/Software IT Hardward and Software Traffic Signs/Maerials Curtains Industrial Catering Equipment Vehicles Consumables Laundry Equipment Workshop Equipment Domestic Appliances Linen, Pillows & Blankets Vehicles, equipment, trailers and tractors Groceries Medical Supplies & Equipment Other (Specify) Electrical Supplies & Equipment Fire Extinguishing Fire Protection & Detection Floor Coverings Food Supplies Fertilisers Medicines NGO's/NBO's Office Consumables Office Equipment Paint Supplies Paper & Stationery 9

10 SECTION D: OWNERSHIP INFORMATION ** 1. List all persons / entities who are owners in the business / trust and indicate their involvement in the management / operations of the business / trust. Proof of disability provided by a recognized related institution, in the case of handicapped persons, must be supplied. If there is insufficient space, kindly attach a copy / copies of this page to this ZDMDB, signed by the same person who signs on behalf of the business / trust. Full Name/name of Business SA Identity No./Business Registration No. SA citizenship (Yes/No) Capacity: Member/Partner/ Proprietor/ Shareholder/ Trustee Business Ownership Percent Gender (Male/ Female) Disability (Yes/No) Race: (Black/ White/ Indian/ Coloured) 10

11 11 2. Please indicate any owner who has a controlling ownership interest in another business** Name of owner Name of other business Registration number of business Position held Ownership

12 2. Please tick the appropriate box: Member/Owner/Family member employed by the municipality? Member/Owner/Family member employed by the government? Member/Owner/Family member is an advisor or consultant contracted with the municipality? Member/Owner/Family member is a councilor in the municipality? YES NO 3. Business Management** Identify by name the Historically Disadvantaged Individual (HDI) status and the length of services of the individuals in the business. Include owners and non-owners responsible for the day-to-day management and Business decisions. Cheque signing Name & Surname Number of years in service Race Signing & co-signing for Loans Business financing decisions Sureties Approval of major purchases Contract signing 12

13 4. Verification of information** I/We, the undersigned, who warrants that he/she is duly authorized to do so on behalf of the supplier, certify that the information supplied in terms of this document including the annexure with the additional information, is correct and accurate and acknowledges that: A. The supplier will be required to furnish documentary proof of the information relating to preferences, if requested to do so. B. If the information is found to be incorrect, then the Zululand District Municipality may, in addition to any remedies it may have: i. Disqualify the supplier/contractor for a particular bid/contract/project it may be considered for, or which has been awarded to the supplier/contractor; ii. Recover from the supplier/contractor all costs, losses or damages incurred or sustained by the Zululand District Municipality as a result of breach of the contract; iii. Cancel the contract and claim any damages which the Zululand District Municipality may suffer by having to make less favourable arrangements after such cancellation; and/or iv. Deregister the supplier on the Supplier Database. 13

14 Signed before The Commissioner of Oaths: Full names of Supplier Representatives: Signature of Supplier Representative: Date signed Signed at Supplier Name: Signed and affirmed before me at: (Commissioner of Oaths) Full Names and Surname: Signature Date signed Business Physical Address: Capacity Area OFFICIAL STAMP 14

15 SECTION E: CHECKLIST Please use this checklist as confirmation that ALL the required information/documents have been submitted. Please indicate with an X The following documents have been attached: Supplier Official Original Tax Clearance Certificate Certified copy of the Company Registration Certificate Proof of Banking Details Valid original or certified copy of the Construction Industry Development Board Registration form The following fields have been completed: Business Particulars Municipalities Financial Information Type of Business Products and Services Ownership Information Business Management Verification of Information FOR OFFICIAL USE I acknowledge that this form has been checked by me, and that all the required Information and Documents have been furnished. Signed: Date: Initials & Surname: 15

16 Annexure A: CERTIFICATION OF BANKING DETAILS Name of Bank Name of Account Branch Code Account Number Type of Account Current Account (Please tick with an X in the applicable box) Savings Transmission Other Account Account (Specify) BANK STAMP Received and stamped by (Name in Block Letters): Signature of Recipient: Date of Receipt: 16