CITY COUNCIL OF TLOKWE
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1 CITY COUNCIL OF TLOKWE APPLICATION TO BE REGISTERED AS AN ACCREDITED PROSPECTIVE PROVIDER OF GOODS/SERVICES IN TERMS OF THE LOCAL GOVERNMENT: MUNICIPAL FINANCE MANAGEMENT ACT, 2003 MUNICIPAL SUPPLY CHAIN MANAGEMENT REGULATIONS 1. FULL REGISTERED NAME OF BUSINESS 2. BUSINESS TYPE/SECTOR 3. REGISTRATION NUMBER OF COMPANY OR CLOSE CORPORATION (Copy of registration certificate to be attached) 4. DETAILS OF OWNERS/SHAREHOLDERS SURNAME FULL NAMES ID NUMBER GENDER RACE 5. TAX REFERENCE NUMBER (Attach an original copy of tax clearance from SARS) 6. VAT REGISTRATION NUMBER IF REGISTERED (Supply a VAT registration certificate) 1
2 7. POSTAL ADDRESS 8. PHYSICAL ADDRESS OF BUSINESS 9. CONTACT DETAILS ACCOUNTS SECTION CONTACT DETAILS 11. MUNICIPAL ACCOUNT NUMBER OF BUSINESS (Copy of latest municipal account to be attached) Name Tel No. Fax No Name Tel. No. Fax No DECLARATION OF ANY CONFLICT OF INTEREST 12.1 If a natural person, are, or have you been in the service of the state/provincial or local government in the preceding twelve months? 12.2 If not a natural person, is or have any directors, managers, principle shareholders or stakeholders been in the service of the state/provincial or local government in the preceding twelve months? 12.3 Has or is a spouse, child or parent of the provider, a director, a manager, shareholder or stakeholder referred to in (a) or (b) in the service of the state in the previous twelve months? YES YES YES NO NO NO If yes, please give details: Name Surname Work number WHAT IS THE CURRENT VALUE OF YOUR BUSINESS? Name of State Department/ Municipality Appointment Date Termination Date 2
3 13 BANKING DETAILS (Attach a copy of proof of company s bank details to verify the following: (a) NAME OF BANK (b) (c) ACCOUNT NUMBER ACCOUNT TYPE (d) BRANCH NAME (e) BRANCH CODE 14. BLACK ECONOMIC EMPOWERMENT ACT INFORMATION (Attach copy of a valid BBBEE certificate (SANAS Accredited. 15. Details of previously disadvantaged Equity Holders (please attach a copy of Share Holding Certificate). SURNAME FULL NAMES ID NUMBER GENDER RACE EQUITY HOLDING % 3
4 16. HUMAN RESOURCE DEVELOPMENT: Number of employees How many Potchefstroom residents are employed by you How many differently abled persons are employed by you(disabled) How many women are employed by you Number of previously disadvantaged individuals employed Details of previously disadvantaged individuals in management position: SURNAME FULL NAMES ID NUMBER GENDER RACE POSITION OCCUPIED 17. Other registered bodies CIDB No SIRA certificate (Compulsory) Please tick relevant box as per SMME Enterprise Table Large 100-Upwards Medium Small Very small 5-10 Micro 0-5 4
5 18.NB! Provide information of the main commodities and/or services in respect of which you wish to be registered as an accredited prospective service provider and attach the list to the application form. NB! I The undersigned SURNAME FULLNAMES ID NR Confirm that I have supplied the correct value of the business herein.further that if the Tlokwe Local Municipality discover the contrary,i accept to be removed from the database without any notice.further, that all information supplied shall only be valid from 1 st January to 31 st December each year and accordingly renewable The requested business information will only be used by the City Council to enable it to adjudicate Bids/Tenders in terms of the Preferential Procurement Policy Framework Act No 5 of 2000, the Municipal Finance Management Act, Act No 56 of 2003 and the Broad-Based Black Economic Empowerment Act, Act No 53 of 2003 and to use such information for purposes of obligatory reporting. The undersigned, who warrants that he/she is duly authorized to do so, confirms hereby that the contents of this document is within his/her personal belief both true and correct. SIGNATURE DESIGNATION DATE & TIME 5
6 Include copies of the following documents in your application (compulsory) Company Registration documents (including CK1 & CK2) ID documents of directors, owners, members of shareholders Valid ORIGINAL tax clearance certificate Copy of Municipal Account where the business is operating Copy of Proof of Bank Details Copy of VATcertificate from SARS(if it does not appear on your tax clearance certificate) Copy of CIDB (if Company is a construction) Copy of valid BBBEE certificate (SANAS Accredited) SIRA certificate for Security companies Postal address: c/o SUPLLY CHAIN MANAGEMENT UNIT TLOKWE CITY COUNCIL PRIVATEBAG X1257 POTCHEFSTROOM 2520 Contact person: GE Nkaunyane Tel:
LUKHANJI DIRECTORATE: FINANCE SUPPLY CHAIN MANAGEMENT UNIT
MUNICIPALITY UMASIPALA MUNISIPALITEIT LUKHANJI DIRECTORATE: FINANCE SUPPLY CHAIN MANAGEMENT UNIT Private Bag X7111 QUEENSTOWN 5320 Telephone: 045 807 2000 Fax: 045 807 2059 Website: www.lukhanji.gov.za
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Kindly furnish me with a written quotation for the supply of the following service: ENVIRONMENTAL IMPACT ASSESSMENT (EIA) CONSULTANCY SERVICES
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