EMNAMBITHI / LADYSMITH MUNICIPALITY · 20110 Mechanical contracts 40210 Land valuation services 20120 Metalwork 40220 Laundry and dry -cleaning services 20130 Painting 40230 Locksmith

EMNAMBITHI / LADYSMITH

MUNICIPALITY

VENDOR REGISTRATION APPLICATION FORM

SUPPLIER’S REGISTERED NAME

_____________________________________________

COMPANY REGISTRATION NUMBER

____________________________

THESE FORMS MUST BE COMPLETED AND SUBMITTED TO:

SUPPLY CHAIN MANAGEMENT UNIT SUPPLY CHAIN MANAGEMENT UNIT ROOM NO. 218 LISTER CLARENCE BUILDING P O BOX 29 221 MURCHISON STREET LADYSMITH LADYSMITH 3370 3370

ENQUIRIES: Greta Viljoen

SUPPLY CHAIN MANAGEMENT SECTION Tel: 036 637 2231 [Ext. 1258]

(2014)

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FOR OFFICE USE

RECEIVED BY: ................................................................................................

(Name & Employee No.)

DATE:................................................................................................................

CAPTURED BY:...........................................................................................

NAME OF ENTERPRISE: ...............................................................................

DATE OF RECEIPT: ......................................................................................

(Application Form)

All questions are to be answered in detail and the application form must be signed.

Note: No faxed registration form will be accepted.

Emnambithi/Ladysmith Municipality will not be held responsible for any mislaid registration forms that have been couriered or posted. Please keep copies of the registration form and all supporting documents submitted, for your own records.

Please ensure that the certification of correctness section is signed and dated. Please ensure that the Company Registration Document is certified and stamped by a Commissioner of Oath.

Please complete the form fully in black ink. Incomplete / unreadable forms will be rejected. Please ensure that your Tax Clearance Certificate is renewed annually and submitted to the Emnambithi/Ladysmith Municipality. If a Company has more than one (1) office/branch, each office must submit a separate application form.

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REQUIRED DOCUMENTATION CHECKLIST

Please ensure that all applicable documents, as listed below, are attached to the registration form

(Please tick appropriate box)

Document Name YES / NO

Original Valid Tax Clearance Certificate Company Registration Certificate (i.e. CK1/CK2 for Close Corporations: Certificate of Incorporation, CM29 and Share Certificates for Companies, Deed of Trust for a Trust; Partnership Agreement for Partnerships etc. (whichever is applicable) Company Resolution of Signatories Original or Certified Copy of “Letter of Good Standing” from the Workmen’s Compensation Commissioner or Its Agent Most recent municipal accounts for your business or your personal residence i.e. Rates, Water, Refuse, electricity (if applicable) Original Certified copy of CIDB (Construction Industry Development Board) Registration Applicable to Construction Companies only. Original Certified copy of ECB (Electrical Constructing Board) Registration and accreditation. Financial Documentation (Proof of Bank Account) Original Cancelled Cheque or Bank Statement (Stamped). Copy of “Acceptable for Food Premises “Certificate” (Compulsory for VIP Catering Purposes) Original Certified copies of ID Documents of Members/ Directors /Owners /Partners/ Share Holders. B-BBEE (Broad-Based Black Economic Empowerment) Status Level Verification Certificate

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1. BUSINESS PARTICULARS

1.1. Name of Business as Registered with Registrar of Companies / Close Corporation

1.2. Trading Name

1.3. Postal Address Postal Code

1.4. Physical Address Postal Code

1.5. 1.Telephone Number

15.2. Cellphone Number

1.5.3. Fax Number

1.5.4. Email Address

1.5.5. Website Address

1.5.6. Preferred Method of Communication E-Mail Fax Telephone

1.6. Contact Person

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1.7. Income Tax Reference Number

If a Sole Proprietor or Partnership please provide Personal Income Tax number/s. 1.8. Unemployment Insurance Fund Number. (If applicable)

Please attach copy of registration form.

1.9. P.A.Y.E. Number (if applicable)

Please attach copy of registration form.

1.10. VAT Registration Number (If applicable)

1.11. Compensation Commissioner Registration Number. (If applicable)

Please attach copy of registration form. 1.12. CIDB / ECB Registration Number (If applicable)

Please attach copy of registration form. Electrical Installation Companies to attach copy of accreditation.

2. BANKING DETAILS 2.1 Name of Banking Institution

2.2. Branch Name Branch Code

2.3. Account Number

2.5. Account Name (Name under which account is operated)

NB: Provide an Original Cancelled Cheque or an Original Bank Statement NOT older than 60 days. 2.6. Type of Account

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3. TYPE OF BUSINESS Please tick the appropriate box

Private Company (Pty) Ltd

Public Company Ltd Close Corporation CC

Sole Proprietor Partnership

Trust Co-operative

Voluntary Associations

Please ensure that certified copies of the appropriate documents, dependent on the type of business, is attached (e.g. CK1/CK2 for Close Corporations; Certified copies of the Certificate of Incorporation, CM29 and Copies of Share Certificates for Public and Private Companies; Deed of Trust for a Trust and the Partnership Agreement for a Partnership).

4. PREVIOUS BUSINESS INFORMATION YES NO

4.1 Did your business exist under a previous name? 4.2. If “YES” what was the previous name? 4.3 Reason for name change

5.1 CLASSIFICATION OF BUSINESS

5.1.1. Classification for Emnambithi/Ladysmith Municipal Supplier Database (Mandatory)

Core Business Area

Sub – Sector

*Please refer to the COMPREHENSIVE LIST of Core Areas and their corresponding sub-sectors as per 5.2 below.

*Two (2) Core Business Areas to be indicated and a maximum of 5 sub-sector commodities from the

sub-sector commodity list.

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5.2. EMNAMBITHI/LADYSMITH MUNICIPALITY SUPPLY CHAIN MANAGEMENT SUB-SECTOR COMMODITY LIST

In order to assist in the classification process, the following must be completed. NB Any vendor may only register for a maximum of two (2) categories

10000 CONSTRUCTION EQUIPMENT AND SUPPLIES 30180 Metering equipment 10010 Air conditioning and temperature control equipment 30190 Prepaid electricity and revenue management

systems

10020 Building equipment and accessories 30200 Power Tools 10030 Building materials Other: Please specify

10040 Ceiling boards, skirtings, etc 10050 Construction machinery 40000 GENERAL SERVICES

10060 Doors and windows 40010 Accommodation and lodging 10070 Electrical systems, lighting, components,

accessories 40020 Advertising, communication, design, editorial

10080 Flooring materials (carpets, tiles, etc.) 40030 Auctioneering services 10090 Plumbing ware and materials 40040 Bookkeeping and accounting services

10100 Roofing materials 40050 Catering and refreshments 10110 Sanitation ware and equipment 40060 Cleaning services

10120 Sand supply 40070 Conferencing facilities and facilitation

Other: Please specify 40080 Contract administration 40090 Courier services

40100 Education and training 20000 CONSTRUCTION SERVICES 40110 Environmental impact studies

20010 Burglar proofing and systems 40120 Freight forwarding and cleaning services

20030 Concrete manufacture and works 40130 General maintenance services

20040 Construction related transport 40140 Health care

20050 Demolition services 40150 Horticulture 20060 Earthworks, drilling and landscaping 40160 Infrastructural maintenance

20070 Electrical installation 40170 Inspection services 20080 Fencing 40180 Insurance

20090 General building work 40190 IT, broadcasting and telecommunication services

20100 Glazing 40200 Interior decorating, refurbishment and upholstery

20110 Mechanical contracts 40210 Land valuation services

20120 Metalwork 40220 Laundry and dry-cleaning services 20130 Painting 40230 Locksmith services

20140 Paving 40240 Mailing services

20150 Plumbing 40250 Management services

20160 Pre-cast concrete manufacture 40260 Miscellaneous equipment and goods hiring

20170 Pump installation 40270 Personnel services

20180 Road works 40280 Pest control and removal services

20190 Sewerage systems and construction 40290 Photographic and graphic design services

20200 Water works and pipelines 40300 Picture framing

20210 Carpentry 40310 Printing

20220 Carpeting / Floor Covering 40320 Procurement Services

20230 Road maintenance 40330 Real estate services

20240 Road marking and signage 40340 Research services 20250 Tiling 40350 Security and safety services

20260 Contractor 40360 Site cleaning

Other: Please specify 40370 Social facilitating

40380 Storage

30000 ELECTRICAL AND MECHANICAL EQUIPMENT, SERVICES

40390 Translation and interpreting services

30010 Bearing supplies 40400 Transport services, general

30020 Bolts, nuts and fasteners 40410 Travel services

30030 Electric cables 40420 Vehicle hire

30040 Electrical component supplies 40430 Vending services

30050 Electrical equipment repairs 40440 Alien plant removal

30060 Hardware supplies 40450 Armed guarding

30070 Lifting equipment 40460 Carpet cleaning

30080 Mechanical seals and packing 40470 Catering – VIP

30090 Pipe and irrigation supplies 40480 Catering – Halaal

30100 Power generation and distribution machinery 40490 Copywriting 30110 Pump spares 40500 Driving school

30120 Small tools 40510 Entertainment

30130 Transfer services 40520 Funeral services

30140 Valves, couplings 40530 Garden services

30150 Water meters, pipes, fittings, PVC, polyethylene 40540 Handyman

30160 HV Fault finding jointing and termination 40550 IT, hardware, software and networking

30170 Service HV and LV Switchgear / Transformers 40560 Lawnmower sales and repairs

40000 GENERAL SERVICES (Cont.) 70220 Project management

40570 LP Gas and paraffin 70230 Quantity surveying

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40580 Marquee tent, chairs and tables – Hiring 70240 Town and regional planning

40590 Decorating marquee tents / halls 70250 Consulting – Electrical

40600 Performance management 70260 Debt collection

40610 Portable toilets hiring – Public 70270 Evacuation system

40620 Portable toilets hiring – VIP 70280 Hazmat

40630 Publishing 70290 Intelligence based investigations

40640 Radio Publicity 70300 Industrial relations consultants

40650 Shelving 70310 Legal services – Compliance

40660 Signwriting 70320 EAP Consultants

40670 Sound Systems 70330 Consulting – Multidisciplinary

40680 Stage hiring 70340 Consulting – OHS 40690 Welding services 70350 Risk assessment

40700 Supermarket 70360 Voice recording

40710 Restaurant 70370 Helicopter Surveillance

40720 Pool, Fish Pond & Fountain Other: Please specify

Other: Please specify 80000 VEHICLE SUPPLY AND TRANSPORTATION

SERVICES

80010 Alarm and tracking systems

50000 OFFICE AND FACILITIES EQUIPMENT AND SUPPLIES

80020 Batteries

50010 Computer equipment, networks and software 80030 Engine overhauls

50020 Consumables 80040 Fuel, oils and lubrications

50030 Corporate gifts 80050 Hydraulics

50040 Domestic, industrial and cleaning equipment 80060 Panel beating

50050 Electronic equipment, including audio-visual equipment

80070 Radiator repairs

50060 Fire protection equipment 80080 Spares and parts

50070 Flowers and plants 80090 Towing services

50080 Food and refreshments 80100 Transmissions

50090 Household furniture, appliances and goods 80110 Tyres and tubes 50100 Office furniture and equipment 80120 Upholstery

50110 Office supplies and stationery 80130 Vehicle fleet management 50120 Printing, copying and photographic equipment 80140 Vehicle supply

50130 Florist 80150 Windscreens

Other: Please specify 80160 Auto electrical services

80170 Auto engineering

60000 MISCELLANEOUS GOODS AND SUPPLIES 80180 Breakdown services 60010 Environmental cleansing equipment, goods and

supplies 80190 Repairs and services

60020 Fire protection equipment, goods and supplies 80200 Diesel and petrol engines 60030 Garden tools 80210 Trailers and tractors

60040 Material and warehousing machinery, equipment 80220 Number Plates 60050 Measuring, testing and observation equipment Other: Please specify

60060 Protective clothing and uniforms 60070 Security equipment, goods and services

60080 Sports and recreational equipment and goods

60090 Blue lights/sirens/emergency equipment Other: Please specify

70000 PROFESSIONAL SERVICES

70010 Accounting, auditing and management services 70020 Architectural services

70030 Consulting engineering – Electrical

70040 Consulting engineering – Environmental 70050 Consulting engineering – other

70060 Consulting engineering – Project management 70070 Consulting engineering – Roads and storm water

70080 Consulting engineering – Sewerage systems 70090 Consulting engineering – Structures and buildings

70100 Consulting engineering – Water systems

70110 Consulting engineering – Geotechnical 70120 Consulting engineering – Solid waste

70130 Engineering services 70140 Financial services

70150 Land surveying

70160 Legal services – Contracts 70170 Legal services – Conveyancing

70180 Legal services – Litigation 70190 Legal services – Other

70200 Consulting engineering – Mechanical

70210 Medical services

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5.3. BUSINESS INFORMATION

Please indicated your appropriate Sector

Agriculture

Mining & Quarrying

Manufacturing

Electricity, Gas & Water

Construction

Retail, Motor Trade & Repair

Wholesaler Trade, Commercial

Catering, Accommodation & Other

Transport & Storage

Finance & Business Services

Community, Social & personal

Other Sectors (s) Please Specify

6. LOCATION OF BUSINESS

AREA TICK

Emnambithi / Ladysmith Municipal Area Municipal Account no:........................................................................................................................

KwaZulu-Natal Province – Outside Emnambithi / Ladysmith Municipal Area Municipality Name:............................................................................................................................. Municipal Account No:........................................................................................................................

Other Province Within South Africa Municipality Name:............................................................................................................................. Municipal Account No.:.......................................................................................................................

International Accredited By:................................................................................................................................... Accreditation No:...............................................................................................................................

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7. BUSINESS INFORMATION

THE FOLLOWING TABLE MUST BE COMPLETED IN ORDER TO ESTABLISH WHETHER A BUSINESS CAN BE CLASSIFIED AS A SMME IN TERMS OF THE NATIONAL SMALL MICRO MEDIUM ENTERPRISE ACT 102 OF 1996.SELECT & TICK THE APPROPRIATE BLOCKS IN COLUMNS 2, 3 & 4

COLUMN 1

COLUMN 2

COLUMN 3

COLUMN 4

Sector/ Sub-sectors in accordance with the Standard Industrial Council CIRCLE WHERE APPLICABLE

Total full time equivalent of paid employees TICK WHERE APPLICABLE

Total annual turnover TICK WHERE APPLICABLE

Total gross asset value (Fixed Property excluded ) TICK WHERE APPLICABLE

Agriculture

MORE THAN 100 MORE THAN R4M MORE THAN R4M

LESS THAN 100 LESS R4M LESS R4M

Mining & Quarrying


LESS THAN 200 LESS R30M LESS R18M Manufacturing


LESS THAN 200 LESS R40M LESS R15M Electricity, Gas & Water


LESS THAN 200 LESS R40M LESS R15M Construction



Retail, Motor Trade & Repair


LESS THAN 100 LESS R30M LESS R5M Wholesaler Trade, Commercial


LESS THAN 100 LESS R50M LESS R8M Catering, Accommodation & Other



Transport & Storage


LESS THAN 100 LESS R20M LESS R5M Finance & Business Services


LESS THAN 100 LESS R20M LESS R4M Community, Social & Personal



Other Sectors (s) Please Specify

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8.1. PROPRIETORS/SHAREHOLDERS/PARTNERS/SOLE PROPRIETORS/TRUSTEES/BENEFICIERIES (OWNER)

List all persons who are OWNERS (as listed above) and, where applicable, provide proof of disability by a recognised related institution. If insufficient space, kindly attach a copy of this page signed by the person who signs on behalf of the business

NAME

ID. NUMBER

DISABILITY INSTITUTION

% SHAREHOLDING

8.2. PLEASE INDICATE ANY OWNER WHO HAS A CONTROLLING OWNERSHIP INTEREST IN ANOTHER BUSINESS

NAME OF OWNER

NAME & ADDRESS OF OTHER BUSINESS

POSITION HELD

BUSINESS TYPE

% OF OWNERSHIP

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8.3. HDI INFORMATION How many Full Time (FT) & Part Time (PT) Staff members are employed by the enterprise?

STAFF MEMBERS

HISTORICALLY DISADVANTAGED INDIVIDUALS

OTHER

PRIORITY

NON PRIORITY

FT

PT

FT

PT

FT

PT

MALE

FEMALE

How many Full Time (FT) & Part Time (PT) Women are employed by the enterprise?

WOMEN


OTHER

PRIORITY

NON PRIORITY

FT

PT

FT

PT

FT

PT

BLACK FEMALE

WHITE FEMALE

How many Full Time (FT) & Part Time (PT) Disabled members are employed by the enterprise?

DISABLED MEMBERS


OTHER

PRIORITY

NON PRIORITY

FT

PT

FT

PT

FT

PT

MALE

FEMALE

Disabled (a permanent impairment of a physical, intellectual or sensory function resulting in restricted use

or lack of ability to perform in a manner considered normal for a human being).

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9. PREVIOUS EXPERIENCE

List the last contract awarded to you (the supplier) or other previous experience relevant to your core business

EMPLOYER / DEPARTMENT

CONTACT PERSON & TEL. NUMBERS

RAND VALUE OF CONTRACT

COMPLETED

SUCCESSFULLY YES / NO

YEAR

10. DECLARATION OF INTEREST

1. No quotation will be accepted from persons in the service of the state*

2. Any person, having a kinship with persons in the service of state, including a blood relationship, may make an offer or offers in terms of an invitation to quote. In view of possible allegations of favouritism, should the resulting contract or part thereof, be awarded to persons connected with or related to a person in service of the state, It is required that the vendor/supplier or their authorised representative declare their position in relation to the evaluating/adjudicating authority and/or take an oath declaring his/her interest.

3. In order to give effect to the above, the following questionnaire must be completed:

3.1. Full name (Vendor/Supplier or Authorised Representative as mentioned above) ......................................................................................................................................

3.2. Identity Number : ............................................................. 3.3. Name of Business : .............................................................. 3.4. Company Registration Number :.............................................................. 3.5. Tax Reference Number :.............................................................. 3.6. VAT Registration Number :..............................................................

3.6.1. Are you presently in the service of the state?* 3.6.2. If so, furnish particulars :

......................................................................................................................................... .........................................................................................................................................

3.7. Have you been in the service of the state for the past twelve months? 3.7.1. If so, furnish particulars:

.........................................................................................................................................

Yes No

Yes No

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..........................................................................................................................................

3.8. Do you have any relationship (family/friend/other) with persons in the service of the state and who may be involved with the evaluation and adjudication of quotations/bids.

3.8.1. If so, furnish particulars : .................................................................................................................................................. ..................................................................................................................................................

3.9. Are you aware of any relationship (family, friend, other) between a supplier and any persons in the service of the state who may be involved with the evaluation and or adjudication of quotations/bids?

3.9.1. If so, furnish particulars : .................................................................................................................................................. ..................................................................................................................................................

3.10. Are any of the company’s Directors/Managers/Principle Shareholders/Partners/Trustees or Stakeholders in the service of state?

3.10.1. If so, furnish particulars : ................................................................................................................................................. .................................................................................................................................................

3.11. Is any spouse, child or parent of the company’s Directors/Managers/ Principle Shareholders/ Partners/Trustees or Stakeholders in service of the state?

3.11.1. If so, furnish particulars: .................................................................................................................................................. ................................................................................................................................................ * MSCM Regulations: “in the service of the state” means to be –

a) A member of – (i) Any municipal council; (ii) Any provincial legislature; or (iii) The national Assembly or the National Council of Provinces;

b) A member of the board of directors of any municipal entity; c) An official of any municipality or municipal entity; d) An employee of any National or Provincial Department, National or Provincial public

entity or constitutional institution within the meaning of the Public Finance Management Act, 1999 (Act No.1 of 1999);

e) A member of the accounting authority of any National or Provincial public entity; or an employee of Parliament or a Provincial Legislature.

Yes No

Yes No

Yes No

Yes No

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CERTIFICATION

I, THE UNDERSIGNED (NAME)..............................................................................................

CERTIFY THAT THE INFORMATION FURNISHED IN THIS DECLARATION FORM IS TRUE AND CORRECT.

I ACCEPT THAT THE STATE MAY ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE.

............................................. .............................................. Signature Date ............................................ ............................................... Position Name of Business

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11. CERTIFICATION OF CORRECTNESS OF INFORMATION AS PROVIDED

I / WE THE UNDERSIGNED, WHO WARRANTS THAT I AM / WE ARE DULY AUTHORISED TO DO SO ON BEHALF OF THE SUPPLIER, CERTIFIES THAT THE INFORMATION SUPPLIED IN TERMS OF THIS DOCUMENT WITH ADDITIONAL INFORMATION IS CORRECT AND ACCURATE AND ACKNOWLEDGE THAT:

1) The supplier will be required to furnish documentary proof of the information relating to preferences, if requested to do so.

2) If the information supplied is found to be incorrect/false then the Emnambithi/Ladysmith Municipality

may, in addition to any remedies it may have:

(i) Disqualify the supplier/contractor for a particular tender/contract/project it may be considered for, or which had been awarded to the supplier/contractor;

(ii) Recover from the supplier /contractor all costs, losses or damages incurred or sustained by the

Emnambithi/Ladysmith Municipality as a result of breach of the contract; (iii) Cancel the contract and claim any damages which the Emnambithi/Ladysmith Municipality may

suffer by having to make less favourable arrangements after such cancellation: and/or;

(iv) De-register the supplier registered on the Supplier Database. SIGNED ON THIS ____________ DAY OF ____________________ 20_______ AT _______________________

BEFORE A COMMISIONER OF OATH

..................................................................................... SIGNATURE OF AUTHORISED REPRESENTATIVE _______________________________________________________ NAME OF AUTHORISED REPRESENTATIVE IN BLOCK LETTERS

SUPPLIER’S NAME: (COMPANY) _________________________________________________________________________

F

Signed and affirmed to, before me at, ____________________________ on this __________ day of

___________________ year __________, by the deponent who has acknowledged that he/she knows and

understands, the contents of this document, and he/she acknowledged that he/she has no objection to affirming,

that he/she regards the affirmation to be binding on his/her conscience.

________________________ COMMISSIONER OF OATH FULL NAME: ___________________________________________________________________________

BUSINESS ADDRESS: ___________________________________________________________________________ CAPACITY: ___________________________ AREA: _______________________________