EEMMNNAAMMBBIITTHHII // LLAADDYYSSMMIITTHH MMUUNNIICCIIPPAALLIITTYY

VENDOR REGISTRATION APPLICATION FORM

SUPPLIER’S REGISTRATION 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 195 221 MURCHISON STREET LADYSMITH LADYSMITH 3370 3370

ENQUIRIES: Greta Viljoen

SUPPLY CHAIN MANAGEMENT SECTION Tel: 036 6372231 [Ext. 1258]

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FOR OFFICE USE

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

(Name & Pay 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

ALL documentation is to be provided in its original format

(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

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1.5.6. Preferred Method of Communication E-Mail Fax Telephone

1.6. Contact Person

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 attached 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.

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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 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 Annexure 1 for a COMPREHENSIVE LIST of Core Areas and their corresponding sub-sectors

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

Annexure 1

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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 ANNEXURE 1

CATEGORY 1. CONSTRUCTION – CORE Air conditioning System Electrical Contractors Plumbing & Water Installation

Alarm/Security System/Access Control

Evacuation System Pre-cast Concrete Manufacture

CCTV Surveillance Fencing Pool , Fish Pond & Fountain

Autoclaves General Building Work Road Marking & Signage

Automatic Hangar Doors Glazing Traffic Signs & Signals

Automatic Sliding Doors Hauling/Heavy Equipment Transport Roadworks

Automatic Sprinkle Sand Supply Road Maintenance Brickwork/Masonry Incinerators Solid Waste Disposal

Cabinet/Furniture Making Landscaping/Earthworks Roofing & Waterproofing

Carpeting/Floor Covering Lift & Escalator Sewerage Installation/Reticulations

Tiling Mechanical Contracts Steam Installations & Ancillary Equipment

Ceilings & Partition Metalwork & Burglar Bars Steel Fabrication & Erection

Cladding Contracts Painting & Plastering Stormwater Draining Demolition Site Cleaning Paving

Compressed Air Installation Timber Contractor Concrete Works

Other (Specify)

CATEGORY 2. SERVICES - CORE

Accommodation Protective Clothing, Uniforms Pest Control

Conference Facilities Handyman Performance Management

Advertising/Public Relation Horticultural Services Printing

Auto Repairs & Services HV Fault Finding Jointing & Termination Photography

Auto Electrical Hydraulic Repairs Insurance/Employee Benefits Graphic Design

Bookkeepers Interior/Industrial Design Promotional Material

Carpeting Cleaning Office Maintenance Trophies & Medals

Cleaning Services Medical Equipment/Instruments/Supplies Signage

Computer Supplies/Services Copywriting Publishing & Radio Publicity

Corporate Gifts Entertainment Audio Visual Equipment Recruitment Agencies Marquee Tent / Stage / Sound /

Decoration Real Estate

Safety & Security Services Portable Toilets (Public) IT Hardware & Software

Service HV & LV Switchgear /Transformers

Portable Toilets (VIP) IT Maintenance & Computer Equipment

Site Cleaning Catering IT Management

Debt Collection VIP Catering IT Networking

Distribution Halaal Catering Laundry Services / Dry Cleaning

Digging of Graves Cleaning Equipment/Material Transport – Taxis

Educational Services Diesel & Petrol Engines - Repairs Transport – Buses

Fire Extinguishers & Refills Locksmith Services Transport - Trucks

Upholstery / Blinds Media Liaison Telecommunication

Wind Socks for the Aerodrome Mailing / Courier Services Travel Agencies

Funeral Services Medical/Ambulance/Health Care Telephone & Data Line Maintenance

Florist Substance Abuse Testing Equipment Tyre Supplies & Repairs

Garden Services Personnel Services Other (Specify)

CATEGORY 3. PROFESSIONAL SERVICES - CORE

Accountants/Financial Advisor EDMS Consultants Service Pre-Employment Assessment Consultant

Architects EAP Consultants Project Managers

Attorneys/Legal Services Economists Quantity Surveyors

Attorneys/Conveyancing Industrial Relations Consultants Teachers

Archival Services Consultants Job Description Consultants Town Planners Business Info. Management Land Surveyors Training Providers

Geotechnical ( Consultant) Legal Compliance Consultants Translation Services

Civil/Structure (Consultant) Medical practitioners Organisations Development Consulting

Electrical (Consultant) OHS Consulting Contractors

Mechanical (Consultant) Pharmacists Other (Specify) Multidisciplinary ( Consultant) Cleaning Service

Lawnmower Sales/Services Garden Tools & Equipment

Generators & Pumps Sales/Services

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Continued........... →

CATEGORY 4. WHOLESALERS / TRADERS/RETAILERS

Automotive Parts & Batteries Workshop Equipment Refuse Bulk Containers

Groceries, Food Supplies Fuel Supplies Vehicle Equipment Trailers & Tractors

Books, Paper & Stationery Furniture & Office Equipment Fire Protection & Detection

Building Materials/Hardware, Paint Fencing Equipment Grass, Plants, Flower , Seeds & Fertilisers

Domestic Appliances Fire Fighting Equipment Laundry Equipment

Chemicals Consumables Power Tools

Pesticides Food for Game Animals Pressure Cleaners

Cleaning Materials Generating Sets Valves

Electrical Supplies & Equipment Health Safety & Environment Supplies Pumps

Industrial Catering Equipment Live Stock Other Fast Food Outlet Recreational Supplies

Supermarket Bottled Water

Restaurant Refrigeration & Air Conditioning

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

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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

MORE THAN 200 MORE THAN R30M MORE THAN R18M

LESS THAN 200 LESS R30M LESS R18M

Manufacturing

MORE THAN 200 MORE THAN R40M MORE THAN R15M

LESS THAN 200 LESS R40M LESS R15M

Electricity, Gas & Water

MORE THAN 200 MORE THAN R40M MORE THAN R15M

LESS THAN 200 LESS R40M LESS R15M

Construction

MORE THAN 200 MORE THAN R20M MORE THAN R4M

LESS THAN 200 LESS R20M LESS R4M

Retail, Motor Trade & Repair

MORE THAN 100 MORE THAN R30M MORE THAN R5M

LESS THAN 100 LESS R30M LESS R5M

Wholesaler Trade, Commercial

MORE THAN 100 MORE THAN R50M MORE THAN R8M

LESS THAN 100 LESS R50M LESS R8M

Catering, Accommodation & Other

MORE THAN 100 MORE THAN R10M MORE THAN R2M

LESS THAN 100 LESS R10M LESS R2M

Transport & Storage

MORE THAN 100 MORE THAN R20M MORE THAN R5M

LESS THAN 100 LESS R20M LESS R5M

Finance & Business Services

MORE THAN 100 MORE THAN R20M MORE THAN R4M

LESS THAN 100 LESS R20M LESS R4M

Community, Social & Personal

MORE THAN 100 MORE THAN R10M MORE THAN R5M

LESS THAN 100 LESS R10M LESS R5M

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

HISTORICALLY DISADVANTAGED INDIVIDUALS

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

HISTORICALLY DISADVANTAGED INDIVIDUALS

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 IN BLOCK LETTERS

SUPPLIER’S NAME: _________________________________________________________________________

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: _______________________________