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SUPPLIER DATABASE

REGISTRATION

QUESTIONNAIRE

Name of company …………………

Town / City…………………………

FOR OFFICE USE ONLY Date Received: ________________________ Received by: __________________________ IDT Stamp:

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ALL SUPPLIER INFORMATION WILL BE TREATED STRICTLY CONFIDENTIAL. NOTE: a) The information required is mandatory. b) IDT reserves the right to conduct audits and investigations on any

applicant or information supplied in this questionnaire. c) Submit with your application the following documents:

1. An original cancelled cheque or an original stamped letter from the bank, verifying the banking details.(bank letter should not be older than 6 months old)

2. Copy of Company Registration documents. 3. Original Certified Copy of ID documents of Directors/owners/Members/

Shareholders. 4. Valid VAT certificate (where applicable). 5. Valid Tax Clearance Certificate (original). 6. Copy of registration certificate pertaining to your relevant industry. 7. Companies claiming Black Economic Empowerment as per IDT’s

definition (see below) to submit copies of the following:

7.1 An original or (original certified) copy of a BEE Certificate

8. Close Corporations to attach an Association Agreement (Not compulsory)

9. (Pty) Ltd.’s to attach Shareholders Agreement, Memorandum of Association as well as share certificates

The above documents to stipulate management responsibilities, profit sharing, liabilities/responsibilities, management contribution, protection in case of death etc.

BLACK ENTERPRISES

The following is a guide on how Independent Development Trust defines Black Enterprise Companies:

Definition: ‘Black’ means South African citizens who are Black, Indian or Coloured persons and EXCLUDES individuals belonging to such communities from any other country. Black Women-owned Enterprises (BWO):

At least 50% of the voting shares or interests are held and controlled by Black Women, and

Black Women have contributed at least 50% of the required capital, and

Black Women in the enterprise have not been given voting shares or interest just to capture or retain contracts, and

Black Women participate in the day to day management and decision making of the enterprise. They necessarily have the aptitude and potential to understand all issues involved in the running of the

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enterprise including knowledge of the product and market within which their enterprise operates.

In a joint venture, skill must be transferable to the Black Women entrepreneur, which means that the Black Women entrepreneur must have the required educational level and/or aptitude.

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SECTION A A1. BUSINESS INFORMATION

Title (Prof. / Dr / Mr / Mrs / Ms) and Surname: ____________________________________________ (If sole proprietor) ‘Trading as’ name of business: _________________________________________________________ (Contracts/order will be placed on this name and invoices must reflect it) Vat Registration Number: __________________________________ Business Tax Number: _______________________________________ Business Registration Number: _____________________________________ Firm’s Average Turnover: _______________________________________ Total Number of Full Time Employees: _______________________________ Total Number of Part Time Employees: _______________________________ Bodies / Institutes / Trade Assoc. Membership Details: _____________________________ Physical address of business: Building / complex name: __________________________________________________________ Street name and number: ___________________________________________________________ Suburb: _________________________________ City: ______________________________________ Code: __________________________________ Country: ____________________________________ Postal address of business: (This is the address to which an Invitation to render services and orders/contracts must be sent to) P O Box / Private Bag: ______________________City/Town: ________________________Code:_____ Telephone numbers of business: Code: ______ Number: ___________________ Accounts department (Tel no) Code_______ Number: ___________________

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Contact person fax number: Code: _______ Number_________________________ (Will be used by IDT for electronic faxing of Request for Services, Contracts and Purchase Orders) Business e-mail:_____________________________________________________________ Your own business contact person/marketing representative name and telephone number: _________________________________________________________________

If Applicable

Sole Proprietor Title (Prof. / Dr Mr / Mrs / Ms/): _________________________ Sole Proprietor Full Name:_________________________________________ Sole Proprietor ID Number: ________________________________________ Previous Name of Business: _______________________________________ Previous Owners of Business: ______________________________________ ______________________________________________________________

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SECTION B

B1. BANKING INFORMATION

Please attach an original cancelled cheque or an original bank verification letter (Not

older than 6 months)

Account Holder: ___________________________________

Bank Account number: _____________________________

Account type: _____________________________________

Bank: ___________________________________________

Branch Name: _____________________________________

Branch code: ______________________________________

Swift Code (Where Applicable):________________________

All payments will be made electronically directly to your bank account.

Kindly note that it will be your responsibility to inform the IDT, in writing, of any

changes in your banking details.

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KINDLY ENSURE THAT ALL THE SECTIONS BELOW ARE FULLY COMPLETED)

SECTION C: PEOPLE

EMPOWERMENT 1. EMPLOYMENT EQUITY

Black Economic Empowerment (BEE) A BALANCED SCORECARDS MEASURING BROAD BASED BEE SHALL BE USED IN THE ALLOCATION

OF BEE POINTS

LIST OF ALL PARTNERS, PROPRIETORS AND SHAREHOLDERS. (Re (Attach shareholders’ Certificate)

The IDT as a development Agency plans and tracks on a continuous basis, key development

indicators. These select indicators relate to participation of different socioeconomic cohorts. Of

particular importance in this instance is the level of participation of Women, Youth, and People with

disabilities and Black population in the context of South Africa. This information is critical and

Suppliers and service providers should complete this section. It is important to note that this

information is used for statistical, planning for impact as well as tracking and internal reporting on the

cited empowerment indicators.

C1.

COMPLETE THE FOLLOWING INFORMATION FOR EACH PARTNER, PROPRIETOR, SHAREHOLDER, DIRECTOR AND OFFICER OF THE FIRM (e.g. Chairman, Secretary, Director, etc.)

Name

ID: Number

Company OR Trust Reg. Number

Race Gender

M/F

Disabled

Yes/No

Shares

%

Home Address

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C2.

Shareholder’s % Breakdown

% Black Male % Black Female % Black Disabled

% % %

% White Male % White Female % White Disabled

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B2. INDICATE WITH (X) COMPANY B-BBEE RECOGNITION LEVEL

B-BBEE Status Level Contributor Single Entity Joint Venture /

Consortium*

LEVEL ONE CONTRIBUTOR

LEVEL TWO CONTRIBUTOR

LEVEL THREE CONTRIBUTOR

LEVEL FOUR CONTRIBUTOR

LEVEL FIVE CONTRIBUTOR

LEVEL SIX CONTRIBUTOR

LEVEL SEVEN CONTRIBUTOR

LEVEL EIGHT CONTRIBUTOR

NON-COMPLIANT CONTRIBUTOR

Exempted Micro Enterprise (EME)

EME LEVEL THREE CONTRIBUTOR

EME LEVEL FOUR CONTRIBUTOR

*For Unincorporated Joint Venture / Consortium: Consolidated B-BBEE certificate from SANAS, IRBA or any Credible Accredited Verification Agency must be provided

B8. INDICATE WITH (X) COMPANY CIDB RATING GRADE 1 GB OR GBPE

GRADE 2 GB OR GBPE

GRADE 3 GB OR GBPE

GRADE 4 GB OR GBPE

GRADE 5 GB OR GBPE

GRADE 6 GB OR GBPE

GRADE 7 GB OR GBPE

GRADE 8 GB OR GBPE

GRADE 9 GB

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B3. LIST OF ALL PARTNERS, PROPRIETORS AND SHAREHOLDERS.

(Re (Attach shareholders’ Certificate)

B4.

COMPLETE THE FOLLOWING INFORMATION FOR EACH PARTNER, PROPRIETOR, SHAREHOLDER, DIRECTOR AND OFFICER OF THE FIRM

(e.g. Chairman, Secretary, Director, etc.)

Name Race Gender

M/F

Disabled

Yes/No

% of time devoted to firm

Home Address

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(PLEASE ATTACH THE COMPANY’S EMPLOYMENT EQUITY TARGET FOR NEXT FIVE YEARS)

Management Details

List all Managers of the firm

C3.

IDENTIFY BY NAME, RACE, GENDER, DISABLILTY AND LENGTH OF SERVICE, THOSE INDIVIDUALS IN THE FIRM (INCLUDING OWNERS AND NON-OWNERS) RESPONSIBLE FOR DAY-TO-DAY MANAGEMENT AND BUSINESS DECISIONS

Activity Name Race Gender

M/F

Disabled

Yes/No

Manage %

Length of

Service (Years)

Financial Decisions

Management Details

CEO

CFO

Supervision of Field / Production Services

Supervision of Office Personnel

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BBBEE Recognition Level ______________________________________ Percentage Contributor_________________________________________ BBBEE Certificate Number______________________________________ Name of Company Listing BBBEE Certificate________________________________________ Scorecard Type: EME; QSE or GENERIC__________________________

C4.

BBBEE Information

C5.

CIDB GRADING FOR CONTRACTORS

Grade:_____________________

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SECTION D:

OFFICES

D1. LOCALITY/OFFICES PLEASE INDICATE WITH (X) AREAS WHERE YOUR BUSINESS CURRENTLY OPERATES/ AREAS OF REPRESENTATION:

Gauteng

North West

Free State

Mpumalanga

Northern Cape

Limpopo

Western Cape

Eastern Cape

Kwazulu-Natal

Kindly indicate: Head Office Branch Office (s) where represented only.

HEAD OFFICE PHYSICAL ADDRESS:

POSTAL ADDRESS:

CONTACT PERSON:

CONTACT NUMBERS:

EMAIL ADDRESS:

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BRANCHES

PHYSICAL ADDRESS:

POSTAL ADDRESS:

CONTACT PERSON:

CONTACT NUMBERS:

EMAIL ADDRESS:

Note that if the amount of branches exceeds the provided space,

please supply an attachment

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SECTION E: CAPACITY

1. CAPACITY AND PAST PERFORMANCE

E1.

LIST THE THREE LARGEST CONTRACTS/ASSIGNMENTS COMPLETED BY YOUR FIRM IN THE LAST FOUR YEARS

Work performed/Project

/Assignment

Client & Contact Person

Physical Address & Telephone number (land line & mobile)

Professional Fees/ Project Value

E2. LIST THE CURRENT PROJECTS/ASSIGNMENT THAT YOUR FIRM IS INVOLVED IN

Assignment Client Physical Address & Professional & Contact Person Telephone number Fees/Project Value (landline and mobile) 1. 2. 3. 4.

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E3. PREVIOUS APPOINTMENTS BY IDT

Project/Programme Name

Type of project

Contract Start

Contract End

Professional Fees/Project

Value

Financial year

IDT Contact Person & Tel

no.

E4. DID THE FIRM EXIST UNDER A PREVIOUS NAME? YES / NO IF YES, WHAT WAS THE NAME: ______________________________________________

E4.1 WHO WERE OWNERS/ PARTNERS/ DIRECTORS:

TECHNICAL E5. IS YOUR BUSINESS A PERMIT HOLDER UNDER THE SABS, MARK SCHEME? (Y / N )

…………………………………. IF YES, INDICATE PRODUCT(S) FOR WHICH PERMITS ARE HELD, INCLUDING PERMIT NUMBERS

QUALITY E6. HAS YOUR QUALITY MANAGEMENT SYSTEM BEEN ASSESSED & CERTIFIED BY ANY

NATIONAL / INTERNATIONALLY RECOGNISED ACCREDITED BODY (Y / N ) IF YES PROVIDE COPY OF CERTIFICATE.

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F1. TYPE OF FIRM (Tick applicable box)

Close Corporation

Co-Operatives

Company

Joint Venture

One Person Business / Sole Trader

NPO / NGO

Partnership

Trust

Educational Institutions

Section 21 Companies

Municipalities

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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F.3

PROFESSIONAL CAPACITIES

( CONSULTANTS ) (Tick applicable box)

Consulting, Civil and Structural Engineering

Electrical Engineering

Mechanical Engineering

Project Management

Quantity Surveying

Social Facilitator

Architects

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F2. PARTICIPATION CAPACITIES (Tick applicable box)

Electrical / Mechanical Contractor

Joint Venture Partner

Main Contractor

Manufacturer

Prime Contractor

Professional Services

Specialist Sub-Contractor

Sub-Contractor

Supplier

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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F4. PROFESSIONAL CAPACITIES

( CONTRACTORS ) (Tick applicable box)

Building Construction

Civil Construction

Electrical Engineering Works

Marine Construction

Mechanical Engineering Works

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F5. SAFETY (CONTRACTORS) (Tick applicable box)

1. Does your business have an Occupational Health Policy complying to the Occupational Health and Safety Act (OHSA) Yes/No

2. Are you registered with Compensation for Occupational Injuries and Diseases Act (COIDA) Yes/No

COIDA registration number_________________________________

F6. Human Resources

1. Briefly state your Affirmative Action (AA) Policy.

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F8. Proudly South African

Do you get more than 80% of your material from your Local Area

Geographically : Yes ______________________ No ______________________

Place

Nationally : Yes_______________________ No_______________________

Region

Internationally : Yes_______________________ No_______________________

Country

2. Are you registered with Compensation for Occupational for Occupational Injuries and Diseases Act (COIDA) Yes/No

COIDA registration number_________________________________

F7. NAME ALL THE BODIES/INSTITUTES/TRADE ASSOCIATIONS OF WHICH YOU HAVE MEMBERSHIP (E.g. The South African Council of Quantity Surveyors- Reg. No. 1589678)

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F8. Services Offered ( Please chose Three only) (Tick applicable box)

Agriculture Information Technology

Catering

Mining

Communications and related

Recruitment Agencies

Corporate

Retail

Electrical Engineers

Social Facilitators

Farming

Transport

Information Systems

Architectural

Manufacturing

Cleaners

Quantity Surveyors

Safety Clothing and Equipment

Research

Economist

Selected by Government

Events Management

Training and Education

Hospitality

Architects

Land Surveyors

Civil Engineers

Project Management

Construction

Rental / Hiring

Development Consultants

Security

Engineers

Stationery / Office Equipment

Financial

Wholesalers

Printing

Maintenance

Office Furniture Furniture Removals

Legal Land Surveyors

Wholesalers Research

Community, Social and Personal Insurance

Hospital Equipment Consultants

Relocation Services Garden Services

Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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SECTION G:

ATTACHMENTS (CONPLETION OF THIS SECTION IS COMPULSORY)

Please attach certified copies/original of the following documents:

Tick

Fully Completed Supplier Questionnaire

Cancelled cheque or an original bank verification letter

Original Certified Copies of ID Documents of owners / Directors etc.

Company Registration Documents

Shareholders agreements / certificates for companies

Original VAT certificate where applicable

Original valid Tax clearance certificate

Proof of registration with professional body where applicable

JV’S Agreement if any

Disability

Original Certified Copy of BEE Certificate (if Claiming BEE)

CIDB Registration Certificate

Utility Bill

Original Income Tax Exemption Certificate

NPO Registration Documents

Deed Of Trust

NB: The onus is on the supplier to ensure that updated (expiring) documents are submitted at the nearest IDT offices.

SWORN STATEMENT I/we, the undersigned, warrant that I/we am/are duly, authorised to do so, on behalf of the enterprise and certify that:

a) The information furnished is true and correct. b) If misrepresentation to gain any benefit is established, The

Independent Development Trust may in addition to any other remedy it may have

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disqualify the applicant;

restrict the applicant, its shareholders and directors from obtaining business from Independent Development Trust for a period not exceeding 5 years;

in the event that a contract has been concluded, recover from the contractor all costs, losses or damages incurred or sustained as a result of the award of the contract;

cancel the contract and claim any damages suffered by having to make less favourable arrangements after such cancellation; and

c) Independent Development Trust is hereby empowered to take such

steps as it may require verifying information submitted, including, but not limited to, the use of independent auditors or other experts.

d) If there are any changes to the information supplied on this form, I/We

will inform Independent Development Trust’s Supply Chain Management Unit immediately.

Name of Enterprise: …………………………………………….……………………… Signature of Enterprise Representative: ……………………………………………………………………………………. Address: …………………………………………………………………………………….. Telephone no: …....………………………… Date: ……………………………

………………………………………. ……………………………………..

For and on behalf of the company Date

…………………………………………………………..

Capacity of signatory (Position held in Company)

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SECTION H:

DECLARATION OF INTEREST: Item Question Yes No

H.1

Is the company or any of its directors listed on the National Treasury’s Database of Restricted Suppliers as companies or person prohibited from doing business with the public sector? (Companies or persons who are listed on this Database were informed in writing of this restriction by the Accounting Officer/Authority of the institution that imposed the restriction after the audi alteram parterm rule was applied). The Database of Restricted Suppliers now resides on the National Treasury’s website (www.treasury.gov.za) and can be accessed by clicking on its link at the bottom of the home page.

H.2

If so, furnish particulars:

H.3

Is the company or any of its directors listed on the Register for Tender Defaulters in terms of section 29 of the Prevention and Combating of Corrupt Activities Act No 12 of 2004)? The Register for Tender Defaulters can be accessed on the National Treasury’s website (www.treasury.gov.za) by clicking on its link at the bottom of the home page.

Yes No

H.4

If so, furnish particulars:

H.5

Was the company or any of its directors convicted by a court of law (including a court outside of the Republic of South Africa) for fraud or corruption during the past five years?

Yes No

H.6

If so, furnish particulars:

H.7

Was any contract between the company and any organ of state terminated during the past five years on account of failure to perform on or comply with the contract?

Yes

No

H.8

If so, furnish particulars:

H.9

Are members/employees of the company/suppliers also employees of the Independent Development Trust?

Yes

No