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Umtshezi Municipality

Database Registration Form

PO Box 15

Estcourt

3310

Tel: 036-342 7800

NAME OF COMPANY

_____________________________________________________________________________________________

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(1) CORRECTNESS OF INFORMATION AFFIDAVIT The following information must be supplied in full by the Supplier/Service provider 1. BUSINESS / ENTERPRISE PARTICULARS

a. Name of Company/Enterprise: .......................................................................................................

b. Postal Address: ...............................................................................................................................

Physical Address: ...........................................................................................................................

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

Telephone No: ...................................................... Fax no: ..........................................................

Cell No: .........................................................................................................................................

a. Contact person: (Print Name) .........................................................................................................

b. Business Registration No : .............................................................................................................

c. Company/Enterprise Income Tax No : ...........................................................................................

d. PAYE No :.....................................................................................................................................

e. VAT Registration No:......................................................................................................................

f. Unemployment Insurance Fund No: ................................................................................................

g. Workmen Compensation Registration No: ......................................................................................

h. Regional Council/District Council no: .............................................................................................

DECLARATION OF INTEREST

1. No bid will be accepted from persons in the service of the state∗.

2. Any person, having a kinship with persons in the service of the state, including a blood relationship, may make

an offer or offers in terms of this invitation to bid. In view of possible allegations of favouritism, should the

resulting bid, or part thereof, be awarded to persons connected with or related to persons in service of the state, it

is required that the bidder 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 and submitted with the

bid.

3.1 Full Name: …………………………………………………………………………

3.2 Identity Number: …………………………………………………………………

3.3 Company Registration Number: …………………………………………………

3.4 Tax Reference Number: …………………………………………………………

3.5 VAT Registration Number: ………………………………………………………

3.6 Are you presently in the service of the state∗∗∗∗ YES / NO

∗∗∗∗ 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;

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3.6.1 If so, furnish particulars.

………………………………………………………………

………………………………………………………………

3.7 Have you been in the service of the state for the past YES / NO

twelve months?


………………………………………………………………

………………………………………………………………

(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 (f) an employee of Parliament or a provincial legislature.

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 or adjudication of this bid?


………………………………………………………………

………………………………………………………………

3.9 Are you, aware of any relationship (family, friend, other)

between a bidder and any persons in the service of the state who

may be involved with the evaluation and or adjudication of this

bid?

3.9.1 If so, furnish particulars

…………………………………………………………….

…………………………………………………………….

YES / NO

YES / NO

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3.10 Are any of the company’s directors, managers, principal YES / NO

shareholders or stakeholders in service of the state?


………………………………………………………………

………………………………………………………………

3.11 Are any spouse, child or parent of the company’s directors, YES / NO

managers, principal shareholders or stakeholders in service

of the state?


………………………………………………………………

………………………………………………………………

CERTIFICATION

I, THE UNDERSIGNED (NAME) ………………………………………………………………………

CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS

CORRECT.

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

BE

FALSE.

…………………………………..

……………………………………..

Signature Date

………………………………….

…………………………………………………………………………

….

Position Name of Bidder NB. COPIES OF VARIOUS REGISTRATION CERTIFICATES MUST BE SUPPLIED. Please tick the appropriate box for the certificates supplied.

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Public Company Ltd Certified Copy of Certificate of Incorporation (CM3) Private Company (Pty) LTD Certified Copy of Certificate of Incorporation (CM3) Close Corporation CC Certified Copy of CK1 Document or CK2 if applicable Sole Proprietor Copy of regional council registration Partnership Refer to item …..for information required Joint Venture Refer to Item ….for information required All Original, Tax Clearance Certificate, Valid

2. FINANCIAL DETAIL (BANKING)

2.1 Name of banking institution: ..........................................................................................................

2.2 Branch: .............................................. Branch No………………………………………….

2.3 Town/City: ....................................................................................................................................

2.4 Banking account number: ...............................................................................................................

2.5 Name under which the account is operated: ................................................................................... NB: DOCUMENTARY PROOF OF BANKING INSTITUTION MUST BE SUPPLIED (Cancelled cheque or letter from Bank) 3. PARTICIPATION

Are you participating on this database as (tick one block)

Prime Contractor

Sub-Contractor

Manufacturer

Joint Venture Partner

Supplier

Professional services

Other, specify below (Agency)

NOTE: All pages of this Affidavit must be initialed by both the Deponent and the Commissioner of Oaths.

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

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

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

4. PRINCIPAL BUSINESS ACTIVITY: (Tick the category of business that applies to your company)

Stationery Masonry Contractor Other (Specify)

Hardware Catering

Building Contractor Consultant

Motor Repairs Legal Adviser

Welding Computer Training

Electrical Installations General Supplier

Plumbing Contractor Supplier of Fuel

5. COMPANY/ENTERPRISE INFORMATION

In which of the categories mentioned in the table below do you (the supplier/service provider) fall?

(Mark with an x where applicable.) See attached.

Annual Turnover R5 to 25 million R1.25 to R5 million Less than R1.25 million

Assets of the Company R1 to R5 million R0.25 to R1 million Less than R0.25 million

Number of Employees Between 76 and 150 Between 9 and 75 Between 1 and 8

6. PARTICULARS OF EMPLOYEES

State the total numbers of permanent and temporary staff employed

BLACK COLOURED INDIAN WHITE HANDICA

P

SUB-

TOTAL

GRAN

D

TOTA

L

P T P T P T P T P T P T

MALE

FEMALE

7. PARTICULARS OF EMPLOYERS

State the number of Males/ Females that own the company.

Number of Males

Number of Females

8. What percentage of share is owned by Females: _____________%


MEDIUM SMALL MICRO

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9. PREVIOUS EXPERIENCE

List the last 4 contracts/quotations awarded to you or previous experience with other firms/companies related

to the type of work/services that you can offer the Umtshezi Municipality


10. CERTIFICATION OF CORRECTNESS OF INFORMATION SUPPLIED IN THIS DOCUMENT

AND THE ATTACHED ANNEXURE RELATING TO THE PREFERENCE CLAIM

I/ WE THE UNDERSIGNED, WHO WARRANTS THAT HE/SHE IS DULY AUTHORIZED TO DO SO

ON BEHALF OF THE SERVICE PROVIDER/SUPPLIER CERTIFIES THAT THE INFORMATION

SUPPLIED IN TERMS OF THIS DOCUMENT IS CORRECT AND ACCURATE AND ACKNOWLEDGES

THAT:

The Service provider/Supplier will be required to furnish documentary proof of the claims if requested to

do so.

If the information supplied is found to be incorrect then the UMTSHEZI MUNICIPALITY may:-

10.1. Recover from the Service provider/Supplier all costs, losses or damages incurred or sustained by the

State as a result of the award of the contract/service, and/or

10.2. Cancel the contract/service and claim any damages which the State may suffer by having to make

favorable arrangements after such cancellations: an/or

10.3. Impose a penalty on the Service provider/Supplier not exceeding 5% of the contract/service value.

SIGNED ON THIS .................. DAY OF ..................................................... AT ...........................................................

BEFORE THE COMMISSIONER OF OATHS

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

SIGNATURE ON BEHALF OF THE (TENDERER’S NAME) .............................................................................

IN BLOCK LETTERS ……………………………….……………………………………………………………

*

Signed and Sworn 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

has acknowledged that he/she has no objection to taking the prescribed oath, that he/she regards the prescribed oath to

be binding on his/her conscience and he/she uttered the following words: “I swear that the contents of this document

are true and correct, so help me God”

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

COMMISSIONER OF OATHS

FULL NAME : ..............................................................................................................................

BUSINESS ADDRESS: ................................................................................................................

CAPACITY:.......................................................... AREA: ..........................................................


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CONDITIONS PERTAINING TO TARGETED PROCUREMENT

FOR CONTRACTS/SERVICES UNDER R58,000.00

Prime Contracts (Minor) Definitions and Interpretations Affiliated Entity Affirmable Business Enterprise (ABE)

1. The following words and expressions having capital initial letters, shall have the meanings

indicated. 1.1. A business entity which has control of or the power to control another business entity, albeit indirectly, e.g.,

where a third person has control of or has the power to control both entities. Indicators of control shall, without limitation, include interlocking management or ownership, identity of interests among family members, shared facilities and equipment, or common use of employees.

1.2. This Condition of procurement refers to and is read with the Conditions Pertaining to Targeted Procurement for

Contracts/Services Under R58 thousand rands included in these documents. 1.3. Defined terms have the meanings given to them in the Specification. 1.4. A business which adheres to statutory labour practices, is a legal entity, registered with the Department of Inland

Revenue and a continuing and Independent Enterprise for profit, providing a Commercially Useful Function and:

a) which is at least two thirds Owned by one or more Previously Disadvantaged Individuals or, in the case of a company, at least two thirds of the shares are owned by one or more Previously Disadvantaged Individuals; and

b) whose management and daily business operations are in the control of one or more of the Previously Disadvantaged Individuals who effectively own it:- provided, however, that the annual average turnover excluding Value Added Tax (VAT) of the business during the lesser of the period of which the business has been operating and the previous three financial years does not exceed:

• R25 millions in respect of contractors/service providers who generate more than 75% of their turnover as

Prime Contractors • R10 million in respect of contractor/service providers who generate less than 25% of their turnover as

Prime Contractors/Service providers (labour and material sub-contractors) • R2,5 million in respect of labour-only sub-contractors • R10 million in respect of Manufacturers • R15 million in respect of Suppliers • R2,5 million, exclusive of any turnover generated in respect of out sourced activities which the enterprise

does not have the in-house competence and expertise to perform, in respect of professional services providers, and

• R2,5 million in respect of other service providers, e.g. transporters and that the sum of the average Annual turnovers over the same period of all the business concerns which are under the Control of Previously Disadvantaged Individuals within the business entity and Affiliated Entities does not exceed one and a half (1.5) times the maximum allowable annual average turnover for the particular category of enterprise as set out in b) above, seeking ABE status.

NOTE: The restriction on turnover of all Affiliated Business Entities applies only in respect of the category of work for which the ABE participates in the performance of the Contract/Service. This in practice means that where Previously Disadvantaged Individuals have interests in a business not operating in the field in which an ABE is seeking participation in the Contract/Service, such business turnovers are not considered in determining the total annual average turnover limits.

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Commercially Useful Function 1.3. The possession and exercise of legal authority and power to manage the assets, goodwill and daily operations of

a business and the active and continuous exercise of appropriate managerial authority and power in

determining the policies and directing the operations of the business.

Control 1.4. The performance of real and actual work, or the provision of services, in the discharge of any contractual

obligation, which shall include but not be limited to the performance of a distinct element of work which the business has the skill and expertise to undertake and the responsibility for management and supervision.

Executive Director 1.5. A partner in a partnership, a director of a company established in terms of the Companies Act 1973, (Act 61 of

1973) or a member of a close corporation registered in terms of the Close Corporation Act, who, jointly and severally with her other partners, co-directors or co-members, as the case may be, bears the risk of business and takes responsibility for the management and liabilities of the partnership, company, or close corporation.

Independent Enterprise 1.6. An enterprise which is free of any degree of direct or indirect Ownership, or Control, by any firm which

engages in activities similar to those which the enterprise performs, or by any Executive Director of such a firm who is not a Previously Disadvantaged Individual.

NOTE: Any enterprise whose owners include firms which engage in the majority of activities that would be

required of a Prime Contractor in the execution of the Contract/Service cannot claim Affirmable Business Enterprise or Women Equity Ownership status. Likewise any enterprise which has any non-PDI Executive Directors who have interests in such firms cannot claim such status.

Manufacturer 1.7. A firm that operates or maintains a factory or establishment that produces on its premises materials or supplies

required by the Prime Contractor for the performance of the Contract/Service. Owned 1.8. Having all the customary incidents of ownership, including the right of dispositions and sharing all the risks and

profits commensurate with the degree of ownership interests as demonstrated by an examination of the substance, rather than the form of ownership arrangements.

Historically Disadvantaged Individuals (HDI) 1.9. Individuals who, being South African citizens, are socially and economically disadvantaged by the legacy of

the South African political dispensation prior to April 28, 1994. For the purpose of the Contract, the refutable presumption shall be made that individuals who fall into population groups that had no franchise in national elections prior to the introduction of the 1984 constitution and the tricameral parliamentary system, are Previously Disadvantaged Individuals, subject to persons who obtained South African citizenship after 2 February 1990, demonstrating traceable South African parentage. It is incumbent on individuals to demonstrate their claims to fall into such population groups on the basis of identification and association with and recognition by the members of such group.

Prime Contractor/Service Provider 1.10. A contractor/service provider who contracts with an employer as the principal or main contractor/service

provider or as a joint venture partner to such contractors, to provide goods, services and works.

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Supplier 1.11. A firm that: a) owns, operates or maintains a store, warehouse, or other establishment in which materials or supplies are

bought, kept in stock and regularly sold to the public in the usual course of business; and b) engages as its principal business and in its own name, in the purchase and sale of the products. Woman 1.12. A female person who is a South African citizen and a female at birth. Women Equity Ownership (WEO) 1.13. The collection Ownership percentage of full time Executive Directors within an enterprise who are Women. Local 1.14 A Manufacturer, Service Provider or Supplier with its main office situated and operated

In the Umtshezi Municipal area. 1.15 Also suppliers who has a fully fledged office in Umtshezi qualifies. Adjudication of quotations on a point system 2. The following shall be the system of Adjudicating Contracts/Services on a points system. 2.1. Adjudication Using a Points System : Allign to PPPFA

Responsive Quotations will be adjudicated by the Umtshezi Municipality using a system which awards points on the basis of:

• HDI - No Franchise - Women - Disable • The status of the enterprise in terms of ownership • Affirmable Business Enterprises • Local Preference The Umtshezi Municipality will normally award the Quotation to the Supplier/service provider obtaining the

highest number of points, but will not bind itself to do so. 2.2. Points Awarded for Price (Qp)

A maximum of 87.5 points is allocated to the quotation with the lowest price as per specification/requirements and points for other and points for other Suppliers/Service Providers are calculated using the following formulae:

PS= 80 (1 - (PE-Pmin)

Pmin Where:

Qp= Points for quotation under consideration Pm = Price of the lowest quotation received

P = Price of the quotation under consideration 2.3. Points Awarded in respect of the Status of the Enterprise

A maximum of 20 (twenty) points can be awarded to businesses which comply & shared according to your

preferences are legal entities registered with the South African Revenue Service, are continuing and

Independent Enterprises for profit which perform Commercially Useful Functions and have been operating as

such for at least 3 months and that they undertake to execute a substantial portion of the Contract/service with

their own resources and not to subcontract any portions of the quotation for which they, in the opinion of the

Umtshezi Municipality, have the in-house competence and expertise to perform.

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Total Adjudicated Points

The total number of adjudicated points awarded (AP) is the sum of: Qp + AB + WE + LP (not to exceed 100) Process to be confidential 3. The following notes pertain to process confidentiality 3.1. Information supplied by Service providers/suppliers and information relating to clarification,

evaluation and adjudication of quotations and the award of contracts/service will not be disclosed to Service providers/suppliers or any other person not officially concerned with such processes.

3.2. Any effort by a Supplier/service provider to influence the Municipalities processing of quotations or

the award of the Contracts/services may result in the rejection of his/her quotation. Documentation to be Submitted in support 4. The following document must be submitted by the service provider/supplier in support 4.1. Service provider/supplier who wish to claim points in respect of their enterprise status must complete

an Application Form for the Award of Points in respect of the Status of an Enterprise (bound in this document) and shall, as relevant, include in their submissions the following duly completed forms:

• Affirmable Business Enterprise Declaration Affidavit • Women Equity Ownership Declaration Affidavit • Local preference should be a person who has a business for a period longer than 6 months and is a permanent resident for one year or more

4.2. The failure to submit completed forms and / or the submission of incomplete forms referred to in 4.1.

shall be deemed to imply that the Service provider/supplier is not claiming points in respect of his enterprise status, in which case points will be awarded only on the basis of the quoted price.

Penalty for falsifying the Declaration Affidavit 5. The following shall be the method of calculating penalties for falsifying the declaration Affidavits or

change in enterprise status offer award of supplier/service provider without written consent from the Municipality.

5.1. Where the Supplier/Service Provider was adjudicated points in respect of enterprise parameters and the

information given in the Declaration Affidavit is found to have been false, the Supplier/Service Provider shall pay the Umtshezi Municipality penalties in an amount equal to one and a half times the number of points claimed and awarded under false pretenses, expressed as a percentage of the contract/service amount, exclusive of VAT and all allowances for contingencies and escalation, at the time of the award of the Contract/Service.

Documentation to be Submitted by the Successful Supplier/Service Provider under Consideration 6. Any other documents that may be required by the Umtshezi Municipality which is relevant to the

Contract/service and which may be required for adjudicating purposes.

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(2) ABE DECLARATION AFFIDAVIT Name of ABE firm:

………………………………………………………………..…………………………………………………………

a) Postal Address:

………………………………………………………………………

…………………………………….

b) Physical Address:

………………………………………………………………………

…………………………………….

………………………………………………………………………

…………………………………….

c) Telephone: ……………………………………………………………………….

d) Facsimile: ……………………………………………………………………….

e) E-Mail: ……………………………………………………………………………………………..

f) Contact person: ……………………………………………………………………………………………..

g) Company registration number # …………………………………………………………………………..

h) Company/enterprise income tax reference number*

…………………………………………………………………..

i) VAT registration number …………………………………………………………………………………. 1. Type of firm (Tick one box)

Partnership One person business/ sole trader Close Corporation Incorporated Company Propriety Limited Company

2. Principal business activities

…………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………

………………….

3. What is the enterprise’s annual average turnover (excl VAT) during the lesser of the period for which

the business has been operating for the previous three financial years: R NOTE: In the case of professional service providers, the turnover is to exclude any turnover generated in respect of outsourced activities which the enterprise does not have the in-house competence and expertise to perform. 4. Company classification (Tick one box)

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Contractor who generates more than 75% of turnover as a Prime Contractor Contractor who generates less than 25% of turnover as a Prime Contractor (i.e. a Sub-contractor)

Labour-only Sub-contractors Manufacturer Supplier Professional service provider Other service providers, e.g. Transporter

# Insert personal income tax number if a one person business and personal income tax numbers of all partner If a partnership • Insert CC number, business licence number, companies act number etc. where available NOTE: All pages of this Affidavit must be initialed by both the Deponent and the Commissioner of Oaths.

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5. Date on which the enterprise was established? 6. List all partners, proprietors and shareholders by name, identity number, citizenship, PDI status and ownership, as relevant.

NAME IDENTITY

NUMBER

CITIZENS

HIP

PDI

STATUS

(YES/NO)

DATE OF

OWNERSHIP

%

OWNED

VOTING

%

NOTE: Where owners are themselves a company, close corporation, partnership, etc., identity of the ownership of

the holding firm. 7. Street addresses of all facilities used by the firm (e.g. warehouses, storage spaces, offices, etc.) Address Facility

7.1.

7.2.

7.3.

8. Do you share any facilities T Yes T No (tick one box)

If yes: which facilities are shared?

With whom do you share facilities (name of firm/individuals)

What are the other firms principal business activities?

9. Describe all property agreements relating to facilities used by the firm and the nature of the agreements indicating

whether facilities are owned or leased by the firm:

FACILITY MONTHLY RENTAL

AMOUNT

OWNER AGREEMENT TYPE

(VERBAL/WRITTEN)


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10. Is the firm registered or does it have a business licence(s)? (Tick one box) T Yes T No

If yes, detail and quote relevant reference numbers and dates

11. Detail all trade associations/professional bodies/ business associations in which you have membership:

12. Did the firm exist under a previous name? (Tick one box) T Yes T No

If yes, what was its previous name? ………………………………………………………………………..

why was it changed? ……………………………………………………………………….. List the previous owners/ partners/ directors:

13. Complete the following information for each partner, proprietor, shareholder, director and officer of the firm (viz.

Chairman, Secretary, Director, etc.)

TITLE NAME PDI STATUS

(YES/NO)

% OF TIME DEVOTED

TO THE FIRM

14. Identify any owner or management office bearer who has an ownership interest in another firm.

OWNER/

MANAGER

NAME & ADDRESS

OF OTHER FIRM

TITLE IN

OTHER FIRM

% OF OWN-

ERSHIP

TYPE OF BUSINESS

OF OTHER FIRM

15. Identify any owner or management official who is an employee of or has duties in another business

enterprise.

NAME DUTIES AS

EMPLOYEE IN

OTHER FIRM

NAME & ADDRESS

OF OTHER FIRM

TYPE OF

BUSINESS OF

OTHER FIRM


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16.1. How many permanent staff members are employed by the firm? Full time: Part time: 16.2. How many staff members have joined the firm in the last 6 months? Full time: Part time: 17. List the major items of equipment, plant and vehicles owned by the firm.

ITEM QUANTITY PRESENT FINANCIAL

LIABILITY (Rands)

18. Identify by name, HDI status and length of service, those individuals in the firm (including owners and non-

owners) responsible for day-to-day management and business decisions.

NAME PDI

STATUS

(YES/NO)

LENGTH OF

SERVICE (YRS)

FINANCING DECISIONS

CHEQUE SIGNING

SIGNING & CO-SIGNING FOR LOANS

ACQUISITION OF LINES OF CREDIT

SURETIES

MAJOR PURCHASE OR

ACQUISITIONS

SIGNING CONTRACTS

NAME PDI

STATUS

(YES/NO)

LENGTH OF

SERVICE (YRS)

MANAGEMENT DECISIONS

ESTIMATING

MARKETING AND SALES

OPERATIONS

HIRING AND FIRING OF

MANAGEMENT PERSONNEL

HIRING AND FIRING OF NON-

MANAGEMENT PERSONNEL

SUPERVISION OF OFFICE

PERSONNEL

SUPERVISION OF FIELD/

PRODUCTION ACTIVITIES


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19. List the following personnel or firms who provide the following services:

SERVICE NAME CONTACT

PERSON

TELEPHONE

NUMBER

ACCOUNTING

LEGAL

AUDITING

BANKING

INSURANCE

20. Identify any amounts of money loaned to your firm, indicating the loan source, date and amount

LOAN SOURCE ADDRESS DATE OF LOAN LOAN AMOUNT

21. List a maximum of five contracts which your firm is presently engaged in and have not yet completed.

CONTRACT

DESCRIPTION

LOCATION EMPLOYER CONTRACT

AMOUNT

EXPECTED

COMPLETION

(MONTH &

YEAR)

22. List the four largest contracts/ assignments completed by your firm in the last three years

WORK PERFORMED FOR WHOM CONTACT PERSON &

TELEPHONE NUMBER

CONTRACT/

FEE AMOUNT


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DECLARATION (to be signed in the presence of a Commissioner of Oaths)

The undersigned, who warrants that he/ she is duly authorized to do so on behalf of the firm, confirm that the firm

complies in all respects with the requirements for registration as an Affirmable Business Enterprise as defined and the

contents of this Affidavit are within my personal knowledge and save where stated otherwise, are to the best of my

belief both true and correct.

Signature:

Duly authorized to sign on behalf of :

Address:

……………………………………………………………………………………………………………………………

……………

……………………………………………………..………………………………………………………………………

…………

Telephone: ……………………………………………..

Signed and sworn to before me at ………………………………….. on this the ……… day of

…………………………….

by the Deponent, who has acknowledged that he/ she knows and understands the contents of this Affidavit, that it is

true and correct to the best of his/ her knowledge and that he/ she has no objection to taking the prescribed oath and

that the prescribed oath will be binding on his/ her conscience.

Commissioner of Oaths


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(3) WOMEN EQUITY DECLARATION AFFIDAVIT

Name of firm:

………………………………………………………………..…………………………………………………………

a) Postal Address:

………………………………………………………………………

…………………………………….

b) Physical Address:

………………………………………………………………………

…………………………………….

………………………………………………………………………

…………………………………….

c) Telephone: ……………………………………………………………………….

d) Facsimile: ……………………………………………………………………….

e) E-Mail: ……………………………………………………………………………………………..

f) Contact person: ……………………………………………………………………………………………..

g) Company registration number # …………………………………………………………………………..

h) Company/enterprise income tax reference number*

…………………………………………………………………..

i) VAT registration number …………………………………………………………………………………. 1. Type of firm (Tick one box)

Partnership One person business/ sole trader Close Corporation Incorporated Company Propriety Limited Company

2. Principal business activities

…………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………

………………….

3. Date on which the enterprise was established? ……………………………………………………………………….. 4. List all partners, proprietors and shareholders by name, identity number, citizenship, PDI status and ownership, as relevant.

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NAME IDENTITY

NUMBER

CITIZENS

HIP

PDI STATUS

(YES/NO)

DATE

OF

OWNER

SHIP

%

OWNED

VOTING

%


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NOTE: Where owners are themselves a company, close corporation, partnership, etc., identity pf the ownership of

the holding firm. # Insert personal income tax number if a one person business and personal income tax numbers of all partner If a partnership * Insert CC number, business licence number, companies act number etc. where available 5. Street addresses of all facilities used by the Service Provider/Supplier (e.g. warehouses, storage spaces, offices,

etc.) Address Facility

7.1.

7.2.

7.3.

6. Do you share any facilities T Yes T No (tick one box)

If yes: which facilities are shared?

With whom do you share facilities (name of firm/individuals)

What are the other firms principal business activities?

7. Is the firm registered or does it have a business licence(s) (Tick one box) T Yes T No

If yes, detail and quote relevant reference numbers and dates

8. Complete the following information for each Woman Executive Director of the firm.

TITLE NAME % OF TIME DEVOTED

TO THE FIRM

HOME

ADDRESS

9. Identify any owner or management office bearer who has an ownership interest in another firm.

OWNER/

MANAGER

NAME & ADDRESS

OF OTHER FIRM

TITLE IN

OTHER FIRM

% OF OWN-

ERSHIP

TYPE OF BUSINESS

OF OTHER FIRM


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10. Identify any owner or management official who is an employee of or has duties in another business

enterprise.

NAME DUTIES AS

EMPLOYEE IN

OTHER FIRM

NAME & ADDRESS

OF OTHER FIRM

TYPE OF

BUSINESS OF

OTHER FIRM

11. How many permanent staff members are employed by the firm? Full time: Part time: _______________ 12. List the major items of equipment, plant and vehicles owned by the firm.

ITEM QUANTITY

13. List the four largest contracts/ assignments completed by your firm in the last three years

WORK PERFORMED FOR WHOM CONTACT PERSON &

TELEPHONE NUMBER

CONTRACT/

FEE AMOUNT

2. WOMEN EQUITY OWNERSHIP CLAIMED 2.1. Women Equity Ownership (WEO) % 2.2. Points claimed in accordance with the following formula WE = 0.0333 x (WEO - 25) % (NOTE: Only applicable when WEO > 25. If WEO < 25 allocate Zero (0) points. NOTE: All pages of this Affidavit must be initialed by both the Deponent and the Commissioner of Oaths.

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complies in all respects with the requirements for registration as an Women Equity Enterprise as defined and the

contents of this Affidavit are within my personal knowledge and save where stated otherwise, are to the best of my

belief both true and correct.

Signature:


Address:

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……………………………………………………..………………………………………………………………………

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Telephone: ……………………………………………..


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(4) LOCAL BUSINESS AFFIDAVIT



complies in all respects with the requirements for registration as a Local Business Enterprise in Umtshezi Municipality

as defined and the contents of this Affidavit are within my personal knowledge and save where stated otherwise, are to

the best of my belief both true and correct.

Signature:


Address:

……………………………………………………………………………………………………………………………

……………

……………………………………………………..………………………………………………………………………

…………

Telephone: ……………………………………………..


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Please tick which of the following affidavits have been completed

(1) Correctness of Information Affidavit

(2) Affirmable Business Enterprise (ABE) Affidavit

(3) Women Equity Ownership (WEO) Affidavit

(4) Local Business Affidavit

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name of company - drakensburgumtshezi.co.za/wp-content/uploads/2012/10/supplier... · name of...

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