THABAZIMBI LOCAL MUNICIPALITY SUPPLIER REGISTRATION FORM
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1 THABAZIMBI LOCAL MUNICIPALITY SUPPLIER REGISTRATION FORM For Enquiries Contact Supply Chain Management Unit Tel No: EXT.113/123 Fax No: Municipal Building Private Bag X530 7 Rietbok street THABAZIMBI Thabazimbi Local Municipality 0380 Page 1 of 19
2 FOR OFFICIAL PURPOSES ONLY: Business Registration No Name of Personnel Issued:... Name of Personnel Received:... Checked By:... Employee Number:... Date:... Signature of Senior Official for Verification:... Signature:... SUPPLIER NUMBER:... NOTE: SUPPLIERS PROVIDING FALSE OR FRAUDULANT INFORMATION OR DOCUMENTATION SHALL SUBJECT THEMSELVED TO IMMEDIATE DISQUALIFICATION. INCOMPLETE SUBMISSIONS WILL NOT BE PROCESSED. THIS INCLUDES THE SUPPORTING DOCUMENTATION AS STIPULATED. Page 2 of 19
3 1. COMPULSORY DOCUMENTATION The Following Documents Are Compulsory For ALL Business Seeking Registration Valid Original Tax Clearance Certificate Latest Rates and Taxes Account A Valid BBBEE Certificate (If Registered) Copy of VAT Registration Certificate (If Registered) Affidavit Confirming Disability (If Applicable) The Following Documents Are Compulsory For The Applicable Businesses Y N N/A Public Company (Listed) CM29 and CM1 (or if Company Details Have Changed With The Registrar Of Companies, Please Provide CM26, CM9, and CM1) Private Company (Pty) Ltd CM29 and CM1 (or if Company Details Have Changed With The Registrar Of Companies, Please Provide CM26, CM9, and CM1) Close Corporation CK 1 (or if Company Details Have Changed With The Registrar Of Close Corporations, Please Provide CM26, CM9, and CM1) Partnership Certified Letter Stating Partners with Identity Documents Included Trust Deed of Trust Non Profit Organization Certificate of Incorporation Section 21 Individual/Sole Proprietor Certified Copy of ID Document of Individual 2. BUSINESS PARTICULARS Registered Name of Business: Trading Name of Business: Holding Company Name (if Applicable) Type of Business (Tick/Select Applicable Box) Public Company (Listed) Private Company (Pty) Ltd Close Corporation Partnership Trust Non Profit Organization Individual/Sole Proprietor Business Registration Number Income Tax Number VAT Registration Number (If Registered) Business Business Website address Business Mobile Number (For SMS Notification Business Telephone Number Business Fax Number Page 3 of 19
4 3. ADDRESS DETAIL Registered Business Address Line 1 Registered Business Address Line 2 Town/City of Registered Business Address: Province of Registered Business Address: Country of Registered Business Address: Postal Code Business Physical Address Line 1: Business Physical Address Line 2: Town/City of Business Physical Address Province of Business Physical Address Postal Code Business Postal Address Line 1: Business Postal Address Line 2: Town/City of Business Postal Address Province of Business Postal Address Postal Code 4. CONTACT PERSON DETAILS Registered Name of Business: Trading Name of Business: Holding Company Name (if Applicable) Contact Person (Tick/Select Applicable Box) Mr. Mrs. Dr Prof Miss Sir First Name Of Contact Person Last Name Of Contact Person Contact Person Job Title Contact Person Identity Number Contact Person Telephone Number Contact Person Fax Number Contact Person Cellphone Number Contact Person Number 5. BANKING DETAILS Account Holder (Name under which it is operated) Name of Bank Bank Branch Name Page 4 of 19
5 Bank Branch Code Bank Account Number Account Type Savings Cheque Transmission 6. COMPANY SERVICE TYPE Select the service type applicable to your business Professional Services Manufacturing Distributor/Supplier/Agent OEM Page 5 of 19
6 7. PRODUCTS AND SERVICES: NB: ONLY FOUR CATEGORIES TO BE CHOSEN Please indicate by ticking an appropriate box below, all products or services your business can supply to Thabazimbi Municipality. ACCOUNTING AND BOOKKEEPING SERVICES ACCOUNTING SERVICES BUSINESS ADMISTRATION SERVICES REPRODUCTION SERVICES BUILDING CONSTRUCTION SERVICES AUDIT SERVICES FINANCIAL SERVICES MANAGEMENT SUPPORT SERVICES PRINTING ENGRAVING PHOTOCOPYING PUBLISHING SPECIALITY BUILDING AND TRADES SERVICES CLEANING SERVICES BOOKBINDING COMMERCIAL AND OFFICE BUILDING CONSTRUCTION SERVICES WELDING SERVICE GENERAL BUILDING AND OFFICE CLEANING AND MAINTENANCE SERVICES LAUNDRY SERVICES Page 6 of 19
7 GARDENING SERVICES ELECTRONICS WASTE REMOVAL SECURITY AND PERSONAL SAFETY COMPUTER SERVICES BUILDING AND FACILITY MAINTENANCE AND REPAIR ENGINEERING SERVICES TRANSPORTATION REPAIR OR MAINTENANCE SERVICES INTERIOR FINISHING AND FURNISHING AND REMODELING SERVICES AUDIO AND VISUAL EQUIPMENT GUARD SERVICES SYSTEM AND SYSTEM COMPONENT ADMINISTRATION SERVICES INFORMATION RETRIEVAL SYSTEMS SOFTWARE MAINTENANCE AND SUPPORT COMPUTER HARDWARE MAINTENANCE AND SUPPORT BUILDING MAINTENANCE AND REPAIR SERVICES PEST CONTROL FACILITY MAINTENANCE AND REPAIR SERVICES INFRASTRUCTURE MAINTENANCE AND REPAIR SERVICES ELECTRICAL AND ELECTRONIC ENGINEERING CIVIL ENGINEERING MECHANICAL ENGINEERING VEHICLE MAINTENANCE AND REPAIR SERVICES PANEL AND PAINT SERVICES VEHICLE CAR WASH SERVICE INTERIOR DESIGN OR DECORATING Page 7 of 19
8 OTHER PROFESSIONAL SERVICES COMPREHENSIVE HEALTH SERVICES HUMAN RESOURCES SERVICES ARCHITECTS SURVEYOR TOWN PLANNERS HEALTH ADMINSTRATION SERVICES HUMAN RESOURCE DEVELOPMENT PERSONNEL RECRUITMENT LABOR OR UNION RELATIONS PERSONNEL SKILLS TRAINING AUDIT TRAINING IT TRAINING INSURANCE AND RETIREMENT SERVICES LIFE AND HEALTH AND ACCIDENT INSURANCE LEGAL SERVICES MAIL AND CARGO TRANSPORT PASSENGER TRANSPORT RETIREMENT FUNDS PENSION FUND INSURANCE SERVICES FOR STRUCTURES AND PROPERTY AND POSSESSIONS BUSINESS LAW SERVICES CIVIL LIABILITY SERVICES POSTAL AND SMALL PARCEL AND COURIER SERVICES ROAD CARGO TRANSPORT Page 8 of 19
9 PASSENGER ROAD TRANSPORTATION MANAGEMENT ADVISORY SERVICES MARKETING AND DISTRIBUTION MATERIALS CATERING HOTELS AND LODGING AND MEETING FACILITIES SPECIALIZED TRADE CONSTRUCTION AND MAINTENANCE SERVICES STORAGE TRAVEL FACILITATION WATER AND WASTEWATER TREATMENT SUPPLY AND DISPOSAL RISK MANAGEMENT CONSULTATION SERVICE PROJECT MANAGEMENT SALES AND BUSINESS PROMOTION ACTIVITIES EVENTS MANAGEMENT AUCTION SERVICES CATERING SERVICES EVENT RENTAL SERVICES HOTELS AND MOTELS AND INNS MEETING FACILITIES HEATING AND COOLING AND AIR CONDITIONING SERVICES PLUMBING SERVICES PAINTING SERVICES ELECTRICAL SYSTEM SERVICES CARPENTRY SERVICES GENERAL GOODS STORAGE TRAVEL AGENTS Page 9 of 19
10 WATER TREATMENT PERFORMING ARTS LIVE PERFORMANCES VISUAL ART SERVICES PAINTERS SERVICES SCULPTORS SERVICES PRODUCTS YOUR BUSINESS CAN PROVIDE: FURNITURE AGRICULTURAL AND FORESTRY AND LANDSCAPE MACHINERY AND EQUIPMENT BUILDING AND CONSTRUCTION MACHINERY AND ACCESSORIES STRUCTURAL BUILDING PRODUCTS INSULATION OFFICE FURNITURE AGRICULTURAL MACHINERY AND COMPONENTS CONSTRUCTION MACHINERY AND EQUIPMENT CONSTRUCTION MATERIAL AND ACCESSORIES BRICKS EXTERIOR FINISHING MATERIALS TILES AND FLAGSTONES THERMAL INSULATION ROOFING MATERIALS ROOFING ACCESSORIES RAIN GUTTERS AND ACCESSORIES SIDING AND EXTERIOR WALL MATERIALS FINISHING MATERIALS AND PRODUCTS Page 10 of 19
11 FENCING INTERIOR FINISHING MATERIALS PLUMBING FIXTURES INDUSTRIAL PUMPS AND COMPRESSORS WALL FINISHING MATERIALS CEILING MATERIALS FLOORING CABINETRY MOLDING AND MILLWORK PARTITION WALLS SANITARY WARE PUMPS CONSTRUCTION AND MAINTENANCE SUPPORT EQUIPMENT HARDWARE PAINTS AND PRIMERS AND FINISHES ADDITIVES LADDERS AND SCAFFOLDING SCREWS BOLTS NUTS WASHERS NAILS HEATING AND VENTILATION AND PAINTS AND PRIMERS PAINT APPLICATORS AND PAINTING ACCESSORIES COLLOIDS (EMULSIONS) Page 11 of 19
12 AIR CIRCULATION AIR CIRCULATION AND PARTS AND ACCESSORIES COOLING (AIR CONDITIONING) HEATING EQUIPMENT AND PARTS AND ACCESSORIES ELECTRICAL EQUIPMENT AND COMPONENTS AND SUPPLIES ELECTRICAL BOXES AND ENCLOSURES AND FITTINGS AND ACCESSORIES ELECTRICAL LUGS PLUGS AND CONNECTORS SWITCHES AND CONTROLS AND RELAYS AND ACCESSORIES CIRCUIT PROTECTION DEVICES AND ACCESSORIES ELECTRICAL HARDWARE AND SUPPLIES CLOTHING CLOTHING ACCESSORIES UNIFORMS PROTECTIVE CLOTHING T-SHIRTS OVERALLS AND COVERALLS ATHLETIC WEAR FOOTWEAR BOOTS SHOES FIRE PROTECTION FIRE FIGHTING EQUIPMENT INFORMATION TECHNOLOGY BROADCASTING AND TELECOMMUNICATIONS COMMUNICATIONS DEVICES AND ACCESSORIES HARDWARE COMPONENTS FOR INFORMATION TECHNOLOGY OR BROADCASTING OR Page 12 of 19
13 TELECOMMUNICATIONS DATA VOICE OR MULTIMEDIA NETWORD EQUIPMENT OR PLATFORMS AND ACCESSORIES OFFICE EQUIPMENT AND ACCESSORIES AND SUPPLIES SIGNAGE AND ACCESSORIES PHOTOGRAPHIC SERVICES OFFICE SUPPLIES (STATIONARY) OFFICE EQUIPMENT TAGS LABELS SIGNAGE SIGNAGE EQUIPMENT IDENTIFICATION DOCUMENTS PERSONAL SAFETY AND PROTECTION PHOTOGRAPHERS AND CINEMATOGRAPHERS SAFETY APPAREL SOFTWARE WATER AND WASTEWATER TREATMENT SUPPLY AND DISPOSAL BUSINESS FUNCTION SPECIFIC SOFTWARE FINANCE ACCOUNTING AND ENTERPRISE RESOURCE PLANNING ERP SOFTWARE WATER TREATMENT AND SUPPLY EQUIPMENT Page 13 of 19
14 CLEANING AND JANITORIAL SUPPLIES CLEANING RAGS AND CLOTHS AND WIPES BROOMS AND MOPS AND BRUSHES AND ACCESSORIES RESTROOM SUPPLIES CLEANING AND DISINFECTING SOLUTIONS CLEANING KITS JANITORIAL EQUIPMENT DAIRY PRODUCTS AND EGGS PREPARED AND PRESERVED FOODS BEVERAGES FLOOR MACHINES AND ACCESSORIES WASTE CONTAINERS AND ACCESSORIES CLEANING EQUIPMENT MILK AND BUTTER PRODUCTS SNACK FOODS CHOCOLATE AND SUGARS AND SWEETENERS AND CONFECTIONARY SANDWICHES AND FILLED ROL PACKAGED COMBINATION MEALS SAVORY PIES AND QUICHES AND PASTIES COFFEE AND TEA NON ALCOHOLIC BEVERAGES FRESH CITRUS JUICE OR CONCENTRATE FRESH BERRY JUICE OR CONCENTRATE CHOCOLATE AND SUGARS AND SWEETENING PRODUCTS Page 14 of 19
15 8. OWNERSHIP List All Persons/Entities, Who Are Owners (i.e. Proprietors/Shareholders/Partners/Sole Proprietors/Trustees/Beneficiaries/Companies/Trusts) In the Business/Trust: FIRST NAME: LNO) RACE: IDENTITY First Name Last Name SA citizenship/ Registered? (Y/N) Race Capacity(Member/ Partner/Proprietor/ Shareholder/Trust ee/beneficiary Youth (Y/N) HDI Franchis e (Y/N) HDI Female (Y/N) % Owner ship Entity Registration No (If Applicable) * Qualify as HDI By Virtue Of Not Having Had Any Franchise In Elections Prior To 1983 Or ** Qualify as HDI By Virtue Of Being Female. *** Qualify as HDI By Virtue Of Having A Disability. 9. OWNER INTEREST IN OTHER BUSINESS First Name of Owner Last Name of Owner Name of Other Business Position Held Percentage Ownership Held Page 15 of 19
16 10. BBBEE/BEE STATUS Select your Business BEE Component/Ownership (Tick/Select Applicable Box) BO (Black Owned, 50% + 1 vote) BE (Black Empowered, 25.1% - 50%) BI (5.1% - 25%) ES (Empowering Supplier, 1% - 5%) WO (White Owned, 0%) Has your Business Undergone a Formal Broad Based Black Economic Empowerment (BBBEE) Accreditation (Tick/Select Applicable Box) If Answered yes state the name of the accreditation agency: Select your Business BEE Component/Ownership (Tick/Select Applicable Box) Level 1 (100 points scored or more) Level 2 (85 to 100 points scored) Level 3 (75 to 85 points scored) Level 4 (65 to 75 points scored) Level 5 (55 to 65 points scored) Level 6 (45 to 55 points scored) Level 7 (40 to 45 points scored) Level 4 (30 to 35 points scored) Non Compliant (Less than 30 Points Scored) Yes No BBBEE Certificate Expiry Date Page 16 of 19
17 11. SMALL MICRO AND MEDIUM SIZED ENTERPRISE (SMME'S) Select Your Business Sector Or Sub-Sectors In Accordance With The Standard Industrial Council: (Tick/Select Applicable Box - ONLY IF YOUR BUSINESS IS CLASSIFIED AS AN SMME ACCORDING TO THE NATIONAL SMALL BUSINESS ACT 102 OF 1996 Agriculture Catering, Accommodation & Other Trade Community, Social & Personal Services Construction Electricity, Gas & Water Finance and Business Services Manufacturing Mining & Quarrying Retail, Motor Trade & Repair Services Transport, Storage & Communications Wholesale Trade, Commercial Agents and Allied Services 12. PREVIOUS BUSINESS INFORMATION Date Current Business Was Established Did Your Business Exist Under a Previous Name Yes No If yes what was the previous name? 13. PREVIOUS EXPERIENCE/REFERENCES List the last 3 contracts awarded to your business or other previous experience related to your core business Page 17 of 19
18 Details of contracts awarded must be in the following order: Contract Description/Client name/client contact detail/location/value of contract (In Rand)/ Date of Completion or Expected Completion Date 14. DECLARATION OF INTEREST Any person, having a kinship with persons in the service of the Thabazimbi Municipality or any other government institutions, including a blood relationship, may apply to register. Disclosure is required in the interest of fairness and transparency. Are you presently in the service of the Thabazimbi Municipality or any other government institutions (Tick/Select Applicable Box) Yes No If so, furnish particulars: Have you been in the service of the Thabazimbi Municipality or any other government institutions for the past 12 months? (Tick/Select Applicable Box) If so, furnish particulars: Yes No Do you have any relationship (family, friend or other) with persons in the service of the municipality? (Tick/Select Applicable Box) Yes No If so, furnish particulars: Is any Spouse, child or parent of the company s directors, managers, shareholders in the service of the Thabazimbi Municipality? (Tick/Select Applicable Box) Yes No If so, furnish particulars: Page 18 of 19
19 15. CERTIFICATION I, (NAME AND SURNAME)...CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS CORRECT. I ACCEPT THAT THE THABAZIMBI MUNICIPALITY MAY ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE. Signature First Name Last Name Identity Number Capacity (Owner, Director, Partner, etc) Date Completed Place Completed The Thabazimbi Municipality will validate the information supplied in the registration form and supporting documentation as part of the accreditation process for suppliers. Page 19 of 19
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