SUPPLIER DATABASE APPLICATION FORMS

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1 SUPPLIER DATABASE APPLICATION FORMS APPROVAL (for office use only) Database reference: Supplier number: 1

2 Inkomati Catchment Management Agency ( ICMA ) Preferred Supplier Database Application Form. Further information contact: or (013) Please complete and return to: Floor 08, MAXSA Building, 15 Ferreira Street, Nelspruit, 1200 or Private Bag x 11214, Nelspruit, 1200 Attention: Supply Chain Management Unit This is an application to be accredited for registration on ICMA s Preferred Supplier Database for the provision of products and services as listed in this document. Kindly complete all the relevant sections and submit this form, the signed declaration and the required supporting documentation to ICMA as indicated. Incomplete submission may result in the unsuccessful accreditation of your application. Registered Company Name: BUSINESS DETAILS Type of firm: Trading Name: ADDRESS Physical Address: Postal address: Province: Province Code: Code: CONTACT-RELATIONSHIP MANAGEMENT Main Contact Person: Cell Phone No: Telephone No: Fax No:(Compulsory) E- Mail: (Compulsory) Website: CONTACT-ACCOUNT DEPARTMENT Main Contact Person Cell Phone No: Telephone No: Fax No: E- Mail: Company/CC No: Registration COMPANY REGISTRATION Year of Establishment VAT No. PAYE: 2

3 Membership to Professional Institutions or Statutory Bodies OTHER INFORMATION National/ International certification for quality standards (e.g. SAB/ ISO Does your enterprise comply with the Occupational Health & Safety Act? Is the enterprise registered with SETA? If so which one? Do you have a Workplace Skills Development Plan? Do you have an Environmental Policy? Are there any pending legal proceedings or previous judgments against the Enterprise or any of the shareholders/ Directors / Members? If so, please explain. Has the Enterprise ever been declared bankrupt, or have any of the Shareholders/ Directors / Members been declared insolvent or rehabilitated from insolvency? If so, please explain. PLEASE SELECT THE SUB-CATCHMENT THAT YOU OPERATE IN (MANDATORY FIELD) Sabie-Sand sub-catchment Crocodile sub-catcment Upper and Lower Komati subcatchment Bushbuckridge Local Municipality Mbombela Local Municipality Albert Luthuli Local Municipality Thaba Chweu Local Municipality Emakhazeni Local Municipality Nkomazi Local Municipality Umjindi Local Municipality TRADE REFERENCES Please provide current, traceable trade references Company Contact Name Telephone number Fax Number Address Do you consent to ICMA conducting a clearance check with National Credit Bureau YES/ NO 3

4 SMME Status of your enterprise: Kindly use this table to determine the SMME status of your enterprise Kindly tick the relevant box in each column A. Sector B. Full-time paid employees C. Annual turnover (R millions) Total gross asset value (R millions) Med Small Very small Micro Med Small Very small Micro Med Small Very small Micro Manufacturing Construction Retail and motor trade Wholesale trade Catering / Accommodation Transport / Storage Finance & business services Repair / Allied services Communications Other trade Commercial agents (e.g. travel agent) Community and social services Personal services (e.g. consulting services) SMME status of your enterprise (kindly tick the relevant box) Micro Very small Medium Large Small Points awarded for B-BBEE Status Level of Contribution In terms of Regulation 2 (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 Contribution Number of points (80/20 System)

5 Non-compliant 0 B-BBEE status level of contribution claimed in terms of table above :.=..(Maximum of 20) PLEASE SELECT YOUR CORE BUSINESS OF OPERATION (MANDATORY FIELD) (Mark with X in application fields) Electrical services Other services Cleaning services Goods supplies Legal services Accommodation Auditors Catering Chattered Accountants Traveling Agency/Transport Events Management Entertainers Employment Agencies Water resource management Information Technology THE FOLLOWING MANDATORY DOCUMENTATION MUST BE SUBMMITTED FOR THE ABOVE CORE BUSINESS OF OPERATION FAILURE TO WHICH THE APPLICATION WILL NOT BE PROCESSED: Electrical services 1 Electrical Contract Association (ECA) certification number and attach certified copy. Optional 2 Electrical Contract Bodies (ECB) certification number and attach certified copy. Mandatory 3 Construction Industry Development Board (CIDB) certification number and attach certified copy. Mandatory Other services 1. Relevant Certification and attach certified copy. Mandatory Cleaning services 1. National Contract Cleaning Association certification and attach certified copy. Mandatory Goods supplies/ IT 1. Accreditation Certificates ( e.g. HP, Proline, Microsoft etc) Legal services 1. Member of any Provincial Law Society in South Africa-registration number and attach certified copy. Must be admitted and in good standing with the society. Mandatory Accommodation 1. Register with South African Grading Council, attach certified copy 2. Registration with the local municipality for certification of accessibility of premises for food preparation, attach certified copy. Mandatory Auditors 1. Registration with the Independent Regulatory Board f Auditors, attach certified copy. Mandatory 5

6 Catering 1. Registration with the local municipality for certification of accessibility of premises for food preparation, attach certified copy. Mandatory Chattered accountants 1. Registration with the South African Institute of Chattered accountants, attach certified copy. Mandatory Travel agency 1. Registration with the International Air Transport Association (IATA), attach certified copy. Mandatory Registration with the Association of South African Travel Agents (ASATA), attach certified copy. Mandatory PRODUCT(S) OR SERVICE (S) OFFERED Product Description TERMS OF APPLICATION 1. Incomplete, false or misrepresented information may result in the unsuccessful accreditation of this application. 2. Procurement or contracts awarded by ICMA based on false, fraudulent and misrepresented information of the service provider or supplier may lead to the Enterprise, its shareholders and directors being restricted from obtaining business from any entity of the Government for a period not exceeding 10 years, in terms of the Preferential Procurement Regulations of ICMA reserves the right to verify any of the representations or references made in this application form. 4. Additional information can be requested by ICMA during its evaluation and accreditation process. 5. ICMA adopts a Zero Tolerance Policy on fraudulent and corrupt practices, investigating every reported case and followed up by the application of all remedies available to the Fund within the full extent of the law. 6. Accreditation of bidders on the ICMA Preferred Supplier Database will be awarded on the absolute discretion of ICMA, but in accordance with internal policies and statutory regulations governing ICMA, and no correspondence will be entered into. 7. Listing on the Database does not guarantee procurement, but rather an opportunity to be invited to quote or bid when the need arises at ICMA DECLARATION I, the undersigned, hereby certify that the information, representations and documents attached to this application is true and correct at the time of completion, and that I am duly authorized to furnish this application on behalf of the Enterprise: Signature: Date: Full names: Does the Enterprise or any of the Shareholders/Members, Directors or Management have any relationship with any Directors, Management or Staff of ICMA? If so, list names of ICMA Personnel and state the nature of the relationship. 6

7 PLEASE ENCLOSE THE FOLLOWING DOCUMENTS WITH YOUR APPLICATION Tick 1. Company / CC Registration documents 2. ID Documents of directors/owners/members/ shareholders 3. Valid TAX Clearance certificate (original document) 4. Company Profile / Corporate Brochure 5. Original cancelled cheque or Bank Certificate verifying the banking details. (Please note that any changes to bank details in future will be subject to the same requirement) 6. B-BBEE Status Level of contribution Certificate issued by SANAS accredited verification agency or registered Auditor approved by IRBA. 7. Shareholders / Association / Partnership Agreement, Memorandum and/ or Articles of Association 8. Registration to Professional Institutions / Statutory Bodies 9. Share Certificates 7

8 -POINTS TO REMEMBER- COMPLETING THE ICMA SUPPLIER ACCREDITATION FORM Business Opportunities Please note that accreditation on the ICMA s Database does not guarantee business opportunities. All procurement will be subject to the procurement and bid policy of the ICMA and applicable legislation. Mandatory fields Certain fields and documentation are mandatory to certain business types. Please ensure that all fields which are mandatory to your business type, marked as Mandatory Field, have been completed failure to which the application won t be processed. If a field is not applicable to your business indicate clearly, mark it as N/A. (Not Applicable) Required documentation Please refer to the Document Requirement Checklist to determine the mandatory supporting documentation required by your business type. Please ensure that all copies of Mandatory documents (certified copies, where applicable) are attached, Failure to which the application won t be processed. Completion of Questions Please answer all questions, as incomplete forms will not be processed. Clearly Mark with an X, to state Yes, No or N/A to the questions asked. Certified Documents Please ensure that a Commissioner of Oaths has certified your Company Registration Documents and other required documents. The Tax Clearance Certificate must be original and valid on the closing date. Processing of accreditation Your completed accreditation form will be processed, and, once verified, will be approved as an accredited supplier on the ICMA s database. A letter of accreditation will be dispatched to the correspondence details supplied. Amendments Please notify the ICMA immediately of any changes to the verified information submitted. Forms that are not legible or incomplete will not be processed on the database. Verification verification of the information supplied will be performed against third party sources such as SARS, DTI, CIDB, ECA, ECB, and SOB etc. The ICMA reserves the right to request additional information or documentation regarding this accreditation form and the request to conduct an audit when necessary Queries Should you have any queries or if you require assistance completing the accreditation form, please contact the ICMA s Supply Chain Management Unit (SCMU). The Information provided in this questionnaire will be treated as confidential. Any appropriate certificate not mentioned in the document but relevant to the field of service, must be submitted. 8

9 Banking Details: Country (Where bank is located) Name of bank Bank key (Branch Number) Bank account (Account Number) Account holder (Only to be filled in if the name of the account holder is not the same as the name of the vendor) Name of account (Type of account) Initials and Surname (Bank official): Signature (Bank official): Date stamp of bank Certified as correct Telephone Number (Bank Official): Date: Duly authorised to sign on behalf of (Name of organisation) address COMMISSIONER OF OATHS: Signature: Date: STAMPMUST BE DATE STAMPED AND SIGNED 9

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