SUPPLIER DATABASE REGISTRATION QUESTIONNAIRE

Transcription

1 SUPPLIER DATABASE REGISTRATION QUESTIONNAIRE Name of company Town / City FOR OFFICE USE ONLY Date Received: Received by: IDT Stamp: 1

2 ALL SUPPLIER INFORMATION WILL BE TREATED STRICTLY CONFIDENTIAL. NOTE: a) The information required is mandatory. b) IDT reserves the right to conduct audits and investigations on any applicant or information supplied in this questionnaire. c) Submit with your application the following documents: 1. An original cancelled cheque or an original stamped letter from the bank, verifying the banking details.(bank letter should not be older than 6 months old) 2. Copy of Company Registration documents. 3. Original Certified Copy of ID documents of Directors/owners/Members/ Shareholders. 4. Valid VAT certificate (where applicable). 5. Valid Tax Clearance Certificate (original). 6. Copy of registration certificate pertaining to your relevant industry. 7. Companies claiming Black Economic Empowerment as per IDT s definition (see below) to submit copies of the following: 7.1 An original or (original certified) copy of a BEE Certificate 8. Close Corporations to attach an Association Agreement (Not compulsory) 9. (Pty) Ltd. s to attach Shareholders Agreement, Memorandum of Association as well as share certificates The above documents to stipulate management responsibilities, profit sharing, liabilities/responsibilities, management contribution, protection in case of death etc. BLACK ENTERPRISES The following is a guide on how Independent Development Trust defines Black Enterprise Companies: Definition: Black means South African citizens who are Black, Indian or Coloured persons and EXCLUDES individuals belonging to such communities from any other country. Black Women-owned Enterprises (BWO): At least 50% of the voting shares or interests are held and controlled by Black Women, and Black Women have contributed at least 50% of the required capital, and Black Women in the enterprise have not been given voting shares or interest just to capture or retain contracts, and Black Women participate in the day to day management and decision making of the enterprise. They necessarily have the aptitude and potential to understand all issues involved in the running of the 2

3 enterprise including knowledge of the product and market within which their enterprise operates. In a joint venture, skill must be transferable to the Black Women entrepreneur, which means that the Black Women entrepreneur must have the required educational level and/or aptitude. 3

4 A1. BUSINESS INFORMATION SECTION A Title (Prof. / Dr / Mr / Mrs / Ms) and Surname: (If sole proprietor) Trading as name of business: (Contracts/order will be placed on this name and invoices must reflect it) Vat Registration Number: Business Tax Number: Business Registration Number: Firm s Average Turnover: Total Number of Full Time Employees: Total Number of Part Time Employees: Bodies / Institutes / Trade Assoc. Membership Details: Physical address of business: Building / complex name: Street name and number: Suburb: City: Code: Country: Postal address of business: (This is the address to which an Invitation to render services and orders/contracts must be sent to) P O Box / Private Bag: City/Town: Code: Telephone numbers of business: Code: Number: Accounts department (Tel no) Code Number: 4

5 Contact person fax number: Code: Number (Will be used by IDT for electronic faxing of Request for Services, Contracts and Purchase Orders) Business e- mail: Your own business contact person/marketing representative name and telephone number: If Applicable Sole Proprietor Title (Prof. / Dr Mr / Mrs / Ms/): Sole Proprietor Full Name: Sole Proprietor ID Number: Previous Name of Business: Previous Owners of Business: 5

6 SECTION B B1. BANKING INFORMATION Please attach an original cancelled cheque or an original bank verification letter (Not older than 6 months) Account Holder: Bank Account number: Account type: Bank: Branch Name: Branch code: Swift Code (Where Applicable): All payments will be made electronically directly to your bank account. Kindly note that it will be your responsibility to inform the IDT, in writing, of any changes in your banking details. 6

7 KINDLY ENSURE THAT ALL THE SECTIONS BELOW ARE FULLY COMPLETED) 1. EMPLOYMENT EQUITY SECTION C: PEOPLE EMPOWERMENT Black Economic Empowerment (BEE) A BALANCED SCORECARDS MEASURING BROAD BASED BEE SHALL BE USED IN THE ALLOCATION OF BEE POINTS LIST OF ALL PARTNERS, PROPRIETORS AND SHAREHOLDERS. (Attach shareholders Certificate) The IDT as a development Agency plans and tracks on a continuous basis, key development indicators. These select indicators relate to participation of different socioeconomic cohorts. Of particular importance in this instance is the level of participation of Women, Youth, and People with disabilities and Black population in the context of South Africa. This information is critical and Suppliers and service providers should complete this section. It is important to note that this information is used for statistical, planning for impact as well as tracking and internal reporting on the cited empowerment indicators. C1. COMPLETE THE FOLLOWING INFORMATION FOR EACH PARTNER, PROPRIETOR, SHAREHOLDER, DIRECTOR AND OFFICER OF THE FIRM (e.g. Chairman, Secretary, Director, etc.) Name ID: Number Company OR Trust Reg. Number Race Gender M/F Disabled Yes/No Shares % Home Address 7

8 C2. Shareholder s % Breakdown % Black Male % Black Female % Black Disabled % % % % White Male % White Female % White Disabled 8

9 B2. INDICATE WITH (X) COMPANY B-BBEE RECOGNITION LEVEL B-BBEE Status Level Contributor Single Entity Joint Venture / Consortium* LEVEL ONE CONTRIBUTOR LEVEL TWO CONTRIBUTOR LEVEL THREE CONTRIBUTOR LEVEL FOUR CONTRIBUTOR LEVEL FIVE CONTRIBUTOR LEVEL SIX CONTRIBUTOR LEVEL SEVEN CONTRIBUTOR LEVEL EIGHT CONTRIBUTOR NON-COMPLIANT CONTRIBUTOR Exempted Micro Enterprise (EME) EME LEVEL THREE CONTRIBUTOR EME LEVEL FOUR CONTRIBUTOR *For Unincorporated Joint Venture / Consortium: Consolidated B-BBEE certificate from SANAS, IRBA or any Credible Accredited Verification Agency must be provided B8. INDICATE WITH (X) COMPANY CIDB RATING GRADE 1 GB OR GBPE GRADE 2 GB OR GBPE GRADE 3 GB OR GBPE GRADE 4 GB OR GBPE GRADE 5 GB OR GBPE GRADE 6 GB OR GBPE GRADE 7 GB OR GBPE GRADE 8 GB OR GBPE GRADE 9 GB 9

10 B3. LIST OF ALL PARTNERS, PROPRIETORS AND SHAREHOLDERS. (Attach shareholders Certificate) B4. COMPLETE THE FOLLOWING INFORMATION FOR EACH PARTNER, PROPRIETOR, SHAREHOLDER, DIRECTOR AND OFFICER OF THE FIRM (e.g. Chairman, Secretary, Director, etc.) Name Race Gender M/F Disabled Yes/No % of time devoted to firm Home Address 10

11 Management Details List all Managers of the firm C3. IDENTIFY BY NAME, RACE, GENDER, DISABLILTY AND LENGTH OF SERVICE, THOSE INDIVIDUALS IN THE FIRM (INCLUDING OWNERS AND NON-OWNERS) RESPONSIBLE FOR DAY-TO-DAY MANAGEMENT AND BUSINESS DECISIONS Activity Name Race Gender M/F Disabled Yes/No Manage % Length of Service (Years) Financial Decisions Management Details CEO CFO Supervision of Field / Production Services Supervision of Office Personnel (PLEASE ATTACH THE COMPANY S EMPLOYMENT EQUITY TARGET FOR NEXT FIVE YEARS) 11

12 C4. BBBEE Information BBBEE Recognition Level Percentage Contributor BBBEE Certificate Number Name of Company Listing BBBEE Certificate Scorecard Type: EME; QSE or GENERIC C5. CIDB GRADING FOR CONTRACTORS Grade: 12

13 SECTION D: OFFICES D1. LOCALITY/OFFICES PLEASE INDICATE WITH (X) AREAS WHERE YOUR BUSINESS CURRENTLY OPERATES/ AREAS OF REPRESENTATION: Gauteng North West Free State Mpumalanga Northern Cape Limpopo Western Cape Eastern Cape Kwazulu-Natal Kindly indicate: Head Office Branch Office (s) where represented only. HEAD OFFICE PHYSICAL ADDRESS: POSTAL ADDRESS: CONTACT PERSON: CONTACT NUMBERS: ADDRESS: 13

14 BRANCHES PHYSICAL ADDRESS: POSTAL ADDRESS: CONTACT PERSON: CONTACT NUMBERS: ADDRESS: Note that if the amount of branches exceeds the provided space, please supply an attachment 14

15 1. CAPACITY AND PAST PERFORMANCE SECTION E: CAPACITY E1. LIST THE THREE LARGEST CONTRACTS/ASSIGNMENTS COMPLETED BY YOUR FIRM IN THE LAST FOUR YEARS Work performed/project /Assignment Client & Contact Person Physical Address & Telephone number (land line & mobile) Professional Fees/ Project Value E2. LIST THE CURRENT PROJECTS/ASSIGNMENT THAT YOUR FIRM IS INVOLVED IN Assignment Client Physical Address & Professional & Contact Person Telephone number Fees/Project Value (landline and mobile)

16 E3. PREVIOUS APPOINTMENTS BY IDT Project/Programme Name Type of project Contract Start Contract End Professional Fees/Project Value Financial year IDT Contact Person & Tel no. E4. DID THE FIRM EXIST UNDER A PREVIOUS NAME? YES / NO IF YES, WHAT WAS THE NAME: E4.1 WHO WERE OWNERS/ PARTNERS/ DIRECTORS: TECHNICAL E5. 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 QUALITY E6. HAS YOUR QUALITY MANAGEMENT SYSTEM BEEN ASSESSED & CERTIFIED BY ANY NATIONAL / INTERNATIONALLY RECOGNISED ACCREDITED BODY (Y / N ) IF YES PROVIDE COPY OF CERTIFICATE. 16

17 F1. TYPE OF FIRM (Tick applicable box) Close Corporation Co-Operatives Company Joint Venture One Person Business / Sole Trader NPO / NGO Partnership Trust Educational Institutions Section 21 Companies Municipalities Other (specify)

18 F2. PARTICIPATION CAPACITIES (Tick applicable box) Electrical / Mechanical Contractor Joint Venture Partner Main Contractor Manufacturer Prime Contractor Professional Services Specialist Sub-Contractor Sub-Contractor Supplier Other (specify) F. 3 PROFESSIONAL CAPACITIES ( CONSULTANTS ) (Tick applicable box) Consulting, Civil and Structural Engineering Electrical Engineering Mechanical Engineering Project Management Quantity Surveying Social Facilitator Architects Other (specify)

19 F4. PROFESSIONAL CAPACITIES ( CONTRACTORS ) (Tick applicable box) Building Construction Civil Construction Electrical Engineering Works Marine Construction Mechanical Engineering Works Other (specify) F5. SAFETY (CONTRACTORS) (Tick applicable box) 1. Does your business have an Occupational Health Policy complying to the Occupational Health and Safety Act (OHSA) Yes/No 2. Are you registered with Compensation for Occupational Injuries and Diseases Act (COIDA) Yes/No COIDA registration number F6. Human Resources 1. Briefly state your Affirmative Action (AA) Policy. 19

20 F7. NAME ALL THE BODIES/INSTITUTES/TRADE ASSOCIATIONS OF WHICH YOU HAVE MEMBERSHIP (E.g. The South African Council of Quantity Surveyors- Reg. No ) F8. Proudly South African Do you get more than 80% of your material from your Local Area Geographically : Yes No Nationally Place : Yes No Region Internationally : Yes No Country 2. Are you registered with Compensation for Occupational for Occupational Injuries and Diseases Act (COIDA) Yes/No COIDA registration number 20

21 F8. Services Offered ( Please chose Three only) (Tick applicable box) Agriculture Catering Communications and related Corporate Electrical Engineers Farming Information Systems Manufacturing Quantity Surveyors Research Selected by Government Training and Education Architects Civil Engineers Construction Development Consultants Engineers Financial Printing Office Furniture Legal Wholesalers Community, Social and Personal Hospital Equipment Relocation Services Information Technology Mining Recruitment Agencies Retail Social Facilitators Transport Architectural Cleaners Safety Clothing and Equipment Economist Events Management Hospitality Land Surveyors Project Management Rental / Hiring Security Stationery / Office Equipment Wholesalers Maintenance Furniture Removals Land Surveyors Research Insurance Consultants Garden Services Other (specify)

22 SECTION G: ATTACHMENTS (CONPLETION OF THIS SECTION IS COMPULSORY) Please attach certified copies/original of the following documents: Tick Fully Completed Supplier Questionnaire Cancelled cheque or an original bank verification letter Original Certified Copies of ID Documents of owners / Directors etc. Company Registration Documents Shareholders agreements / certificates for companies Original VAT certificate where applicable Original valid Tax clearance certificate Proof of registration with professional body where applicable JV S Agreement if any Disability Original Certified Copy of BEE Certificate (if Claiming BEE) CIDB Registration Certificate Utility Bill Original Income Tax Exemption Certificate NPO Registration Documents Deed Of Trust NB: The onus is on the supplier to ensure that updated (expiring) documents are submitted at the nearest IDT offices. SWORN STATEMENT I/we, the undersigned, warrant that I/we am/are duly, authorised to do so, on behalf of the enterprise and certify that: a) The information furnished is true and correct. b) If misrepresentation to gain any benefit is established, The Independent Development Trust may in addition to any other remedy it may have 22

23 disqualify the applicant; restrict the applicant, its shareholders and directors from obtaining business from Independent Development Trust for a period not exceeding 5 years; in the event that a contract has been concluded, recover from the contractor all costs, losses or damages incurred or sustained as a result of the award of the contract; cancel the contract and claim any damages suffered by having to make less favourable arrangements after such cancellation; and c) Independent Development Trust is hereby empowered to take such steps as it may require verifying information submitted, including, but not limited to, the use of independent auditors or other experts. d) If there are any changes to the information supplied on this form, I/We will inform Independent Development Trust s Supply Chain Management Unit immediately. Name of Enterprise:. Signature of Enterprise Representative:. Address:.. Telephone no:... Date:. For and on behalf of the company.. Date.. Capacity of signatory (Position held in Company) 23

24 SECTION H: DECLARATION OF INTEREST: Item Question Yes No Is the company or any of its directors listed on the National H.1 Treasury s Database of Restricted Suppliers as companies 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 Accounting Officer/Authority of the institution that imposed the restriction after the audi alteram parterm rule was applied). The Database of Restricted Suppliers now resides on the National Treasury s website ( and can be accessed by clicking on its link at the bottom of the home page. H.2 If so, furnish particulars: H.3 Is the company 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)? The Register for Tender Defaulters can be accessed on the National Treasury s website ( by clicking on its link at the bottom of the home page. Yes No H.4 If so, furnish particulars: H.5 Was the company 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: H.6 H.7 Was any contract between the company and any organ of state terminated during the past five years on account of failure to perform on or comply with the contract? H.8 If so, furnish particulars: Yes Yes No No H.9 Are members/employees of the company/suppliers also employees of the Independent Development Trust? Yes No 24