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MNQUMA LOCAL MUNICIPALITY
CONTRACTORS DATABASE
APPLICATION FORM FOR THE FINANCIAL YEAR 2014/2015
1
APPLICATION FORM FOR CONTRACTORS TO BE INCLUDED ON THE MNQUMA LOCAL MUNICIPALITY CONTRACTORS DATABASE.
Please note: This form must be completed by all applicants wishing to register as a contractor with the
Mnquma Local Municipality. Please reflect all the resources the firm has such as: Plant,
Machinery, Equipment and Labour. Also reflect the expertise and experience that the company
has other relevant additional documentation may also be attached. The Municipality will
determine the suitability of firms for entry into its database, based on the information provided.
All sections of the application form must be completed in full.
The application form is to be completed by the duly authorised official of the contracting firm.
Please indicate on the space below, if this is a new application and/or update application.
New application/Update application:
Date of application: /_ / .
Once the application is completed return by Hand delivery to:
The Supply Chain Management Unity Mnquma Main Building
Cnr King & Mthatha Street, Office No.16, Butterworth
Or
Att: Supply Chain Management Unit Mnquma Local Municipality
P. O. Box 36
Butterworth
4960 Tel: 047 401 2400
NB: FAXED AND/OR EMAILED APPLICATION WILL NOT BE ACCEPTED!
2
PARTICULARS OF FIRM
1. Name of Firm:
2. Name of the Managing Director:
3. Type of firm (tick relevant box)
Partnership
One person business/sole proprietor
Close corporation
Company
[Pty] Limited
Consortium
Other (specify)
4. Co./CC Registration Number:
5. Vat. Registration Number:
6. Tax reference number:
NB: Insert personal income tax reference number if one-man business and personal
income tax reference numbers of all parties if a partnership.
7. Membership with professional bodies:
[include membership number]_
8. B-BBEE Verification Status Level
3
PREREQUISITES: NOTE: CONTRACTORS WILL NOT BE REGISTERED ON THE DATABASE IF THE FOLLOWING PREREQUISITES ARE NOT MET.
1. Proof of company registration and/or any other form of legal standing must be
submitted
2. A current and original Tax Clearance certificate from South African Receiver of
Revenue Service [SARS] certifying that the taxes of the applicant are in order or that
suitable arrangements have been made with SARS to bring them in order. The Tax
Certificate will be reworded at the allocated space for the VAT number with the words
“compulsory if turnover is more than R300 000”. Where the person is not required to
be registered for VAT, the Receiver of Revenue will write “not required to register”
next to the allocated space for the VAT registration number.
3. Submit proof of Professional Registration with the relevant Professional Body e.g
CIDB Certificate.
4. Submit Company composition on the form attached as Annexure “H”.
5. Complete Annexure “C1”, “C2”, and “D”.
6. Attach Board - Based Black Economic Empowerment (B-BBEE)
Strategy/Transformation Strategies/ strategies to empower the Disabled/physically
challenged.
7. Proof of Registration with the commissioner for compensation (Workman’s
Compensation).
8. Submit a copy of the South African Identity Document.
9. Submit a copy of a company profile.
10. Submit of Letter from the bank confirming banking details and/or cancelled cheque
4
5
CONTACT DETAILS
1. Contact person:
Phone No.:
Cell No.:
Fax No.:
E-Mail:
2. Postal Address:
3.
Physical Address:
Postal Code
Postal Code_
4. Eastern Cape Offices: _
5. National Offices:
CONTRACTORS MUST INDICATE WHAT CATEGORY OR SIZE OF WORK THEY ARE ABLE TO UNDERTAKE:
Micro Projects R0 – R120 000
Small Size Projects R120, 000 – R500, 000
Medium Sized Projects R500, 000 – R1 Million
Large Projects Above R1 Million
6
PLEASE INDICATE THE FIELD OF COMPETENCE YOUR FIRM WILL BE REGISTERING FOR, BY TICKING IN THE BOX: (PROFESSIONAL SERVICE PROVIDERS ONLY)
Road
Tar
Building
Electricity
Wet Services (Plumbing & granadge)
Welding
Specify if other:………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
More than one (1) field of competence may be selected.
Engineering and Construction Plant Hires
Grader 13 tons or more articulating or ridged,
4 X4 Tow Tractor with Grid Roller (not less 13 tons,
Water tanker minimum 8000 with sprayers for road construction with
Capacity to load and discharge pressurized water,
Tracked Excavator minim 18 tonnes fitted with rock bucket,
Tipper trucks 10 M₃s,
Dozer D6 or its equivalent,
4X4 LTB,
8 tone train truck
Skip louder truck
Lobed
Concrete Cutter
Concrete mixer
Grid Roller
7
ANNEXURE C.1
PPAASSTT EEXXPPEERRIIEENNCCEE ((OOTTHHEERR IINNSSTTIITTUUTTIIOONNSS EEXXCCLLUUDDIINNGG MMNNQQUUMMAA LLOOCCAALL
MMUUNNIICCIIPPAALLIITTYY))
Contractors must furnish hereunder details of similar works/service, which they have
satisfactorily completed in the past. The information shall include a description of the Works, the
Contract value and name of Employer.
EMPLOYER
NATURE OF WORK
VALUE OF WORK DURATION AND
COMPLETION DATE
EMPLOYER CONTACT NO.
Supply additional annexures if the above is not adequate
8
AANNNNEEXXUURREE CC..22
PPAASSTT EEXXPPEERRIIEENNCCEE ((MMNNQQUUMMAA LLOOCCAALL MMUUNNIICCIIPPAALLIITTYY OONNLLYY))
Contractors must furnish hereunder details of similar works/service, which they have
satisfactorily completed in the past for Mnquma Local Municipality. The information shall
include a description of the Works, the Contract value and name of Employer.
PREVIOUS AND/OR CURRENT PROJECTS UNDERTAKEN FOR MNQUMA MUNICIPALITY
PROJECT NAME
AWARDED AMOUNT
CONTRACT START
DATE
ANTICIPATED / ACTUAL
COMPLETION DATE
Supply additional annexures if the above is not adequate
9
AANNNNEEXXUURREE DD
CCOOMMPPAANNYY DDEETTAAIILLSS
The following company details schedule must be completed in full. Attach a copy of Founding Statement/ Business Registration.
Registered Company Name: .....................................................................................
.............................................................................................................................
Company Registration Number: ...............................................................................
VAT Number: .........................................................................................................
Bank institution:………………………………………………………………………………………………………
Branch Name: ........................................................................................................
Bank Account Number: ...........................................................................................
Type of Account:……………………………………………………………………………………………………...
Professional Registration Details: .............................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
............................................................................................................................
. Professional Indemnity Details:
................................................................................
.............................................................................................................................
.............................................................................................................................
10
AANNNNEEXXUURREE HH
CCOOMMPPAANNYY CCOOMMPPOOSSIITTIIOONN
GENERAL
All information must be filled in spaces provided. If additional space is required, additional
sheets may be attached. The onus is on the Contractors to fill in all the information. Failure to
do so will result in points being lost under equity. The full company composition is required
including HDI and Non-HDI status. The ownership must accumulate to 100%.
NAME
IDENTITY NUMBER
CITIZE NSHIP
B-BBEE STATUS
VERIFICATI ON LEVEL
DATE OF OWNERSHIP
%
OW
NE
D
%
VO
TIN
G
11
AANNNNEEXXUURREE KK SSOOCCIIAALL
RREESSPPOONNSSIIBBIILLIITTYY
SOCIAL RESPONSIBILITY
BURSARIES AND MENTORSHIP PROGRAMMES PROVIDED BY COMPANY
NAME OF INCUMBENT
TERTIARY INSTITUTION
WHERE STUDIES ARE BEING
CONDUCTED
AMOUNT
ALLOCATED FOR STUDIES
MENTORSHIP PROGRAMME THAT THE INCUMBENT HAS
BEEN PLACED ON
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AANNNNEEXXUURREE FF DDEECCLLAARRAATTIIOONN
OOFF IINNTTEERREESSTTSS
Any legal person, including persons employed by the Municipality, or persons who act on behalf
of the Mnquma Local Municipality or persons having a kinship with persons employed by the
Municipality including a blood relationship, may make an application in terms of this system. In
view of possible allegations of favouritism, should the resulting application or part thereof, be
awarded to persons employed by the Mnquma Local Municipality, or to the persons who act on
behalf of the Mnquma Local Municipality, or persons connected with or related to them, it is
required that the applicant or his/her authorized representative shall declare his position vis-à-vis
the evaluating authority and/or take an oath declaring his/her interest, where –
- the applicant is employed by the Mnquma Local Municipality or acts on behalf of the
Mnquma Local Municipality; and/or
- the legal person on who’s behalf the application is signed, has a relationship with
persons/a person who are/is involved with the evaluation of the submissions, or where it
is known that such a relationship exists between the person or persons for or on who’s
behalf the declarer acts and persons who are involved with the evaluation of the
submissions.
- where the person is employed by any organ of State.
In order to give effect to the above, the following questionnaire shall be completed and
submitted with the applicant.
Are you or any person connected with the applicant, employed by the Mnquma local
Municipality?
Yes/No
If so, state
particulars:
Do you, or any person connected with the applicant, have any relationship (family, friend, other)
with a person employed with the Mnquma Local Municipality or its Administration and who may
be involved with the evaluation, preparation and/or adjudication of these submissions?
Yes/No
If so, state
particulars:
Are you or any other person connected with the applications, employed by any organ of State?
Yes/No
If so, state particulars: .
I a Principal/Director/Manager/Member of the
company called
declare
that I that I am employed (either full time or part time) by the company applying for
the registration on the database and the information furnished, as well as a the
documents submitted in support of the registration, is true and correct in every
respect ; and have been lawfully obtained; the declaration is signed on the
the day of
.
on 20 at
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