supplier profile - development bank of southern … · web viewif yes, indicate product(s) for...

Supplier Information FormFor Incorporated Businesses, Companies and Close Corporations

This is an application to be accredited for registration on DBSA’s Supplier Database for the provision of products and services. Kindly complete all relevant sections and submit this form and the required supporting documentation to DBSA as indicated. Incomplete submission may result in the unsuccessful registration of your application.

All supplier information will be treated strictly as confidential.‘Trading as’ name of business: (This will be used for Contracts/orders. Your Invoices should reflect this name)

Registered name of business:

Registration number of business (CC/Companies):

Date of incorporation:

Jurisdiction of business (i.e. placewhere effective management is carried out):

Income Tax Reference Number

VAT Registration Number:

Bank Account Holder Relationship (Own, Joint or Third party)

Employees’ Tax Reference Number:

Physical address:

Building/complex name:

Number and street name:

Suburb : City :

Code: Country:

Postal address:

Postnet address:

P O Box/Private Bag :

City/Town: Code:

Business Telephone Number: Code: Number:

Alternate Business Telephone Number: Code: Number:

*Account manager fax number: Code: Number:

**Accounting Clerk’s fax number: Code: Number:

Business e-mail address:

Previous business name if applicable:

* For electronic faxing to Account manager** For electronic faxing of APS remittance advices

VAT Reference Numbers

DBSA: 426 012 6711

Development Fund: 420 024 5522

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In order for the DBSA to evaluate whether the supplier is a “Personal Services Provider” as defined in the 4th schedule to the Income Tax Act, the supplier need to answer the following questions by marking the appropriate column with an X. The answers supplied will be used to determine whether the DBSA is obliged to deduct employees’ tax from any payment due to the supplier. If the response to question 9 below is a “No”, the DBSA may require an affidavit from your entity to satisfy the response.

YES NO

1. Is the service to be rendered personally by any person, who is a connected person, in relation to your entity? (For example a shareholder, member or their direct family)

2.How many people do you employ on a full time basis throughout the year, who are engaged in rendering the service excluding support staff (e.g. secretarial employees), shareholders,, members of the company

or close corporation, or their relatives?

Number

3. Would you be regarded as an employee of the DBSA if the service was rendered by the person directly to the DBSA, other than on behalf of the contractor?

4. Do you, the Company, Close Corporation or Trust receive any form of training supplied or paid for by DBSA?

4.1 If “yes”, please specify the nature and extent of the training:

_______________________________________________________________________________________________ _______________________________________________________________________________________________

5. Are you, the Company Close Corporation or Trust free to choose which tools or equipment, or staff, or raw materials, or routines, patents and technology to use in performing your main duties?

6. In order to perform your main duties, do you, or does such a person, Company, Close Corporation or Trust, use any tools or equipment supplied or paid for by DBSA?

7.Are you subject to the control or supervision of the DBSA, as to the manner in which, or hours during which, the duties are performed or are to be performed mainly at DBSA premises in rendering the service? If “YES” please specify the extent of supervision.

_______________________________________________________________________________________________

8.Will the payments to you be based on the results produced or output? I.e. work done.

9.

Will more than 80% of your income, during the year of assessment, from services rendered, consist of or be likely to consist of amounts received directly or indirectly from any one client, or any associated institution, in relation to the client?I.e. although you may perform services for various clients/ customers, do you expect that 80% or more income for the tax year will come from one source?

10.Does your contract contain any elements of an employment contract? [i.e. Job titles, reporting structure in organisation, fixed working hours, employment benefits, performance bonuses (excluding bonus and penalties for early or late delivery)]

11. Does your contract contain any clause that will enable you to receive payment, even if no work was done?

12.Are you obliged to furnish written reports to the DBSA as part of your contract?

Your entity will be required to complete an affidavit on an annual basis in terms of the relevant provisions of the Income Tax Act as amended from time to time. If the response to the above three questions are as follows: 1. “YES”, 2. less than 3 and; 9. “NO”

A copy of the affidavit is available from the DBSA Tax Section on request at: [email protected]

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Business DetailsWhat is your entity’s core business specialisation?

________________________________________________________________________________________List other product(s) or service(s) offered ________________________________________________________________________________________

________________________________________________________________________________________

Section B: Black Economic Empowerment (BEE)1. Please provide the DBSA with a BEE verification certificate issued by an Accredited Verification agency or Verification

Agencies that are in procession of a valid pre-assessment letter from the South African National Accreditation System will be valid. (Notice 354 of 2009)

2. Verification certificates issued by non-accredited verification agencies prior to the 09 th of April 2009 will remain valid for a 12 months from the date of issue

Indicate your Enterprise Turnover per annum

Less than or equal to R 5mGreater than R 5m but less than R15mGreater than R15m and equal to R 25mGreater than R 25m

Section C: Commercial ReferencesName 3 commercial references/referees of previous projects and provide their name(s) and telephone number(s):

1. ____________________________________________________________________________________________

2. ____________________________________________________________________________________________

3. ____________________________________________________________________________________________

Section D: Financial StatusAre there any pending legal proceedings or previous judgements against your business or has your business ever been declared bankrupt? (Y/n) If yes, please elaborate:

________________________________________________________________________________________________

________________________________________________________________________________________________

Section E: Technical Status1. 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:

_____________________________________________________________________________________________

___________________________________________________________________________________________

2. Are you working to National or International Standards? (Y/n) If yes, list products and standards:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Section F: Quality Standards1. Does your business operate a Quality Management System covering the product/service offered

(Y/n) Please elaborate:

______________________________________________________________________________________________

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_____________________________________________________________________________________________

2. Has your Quality Management System been assessed and certified by any National/Internationally recognised accredited body? (y/n) If yes, please provide copy of certificate.

Section G: Safety Standards1. Does your business have an Occupational Health and Safety Policy complying with the Occupational Health

and Safety Act (OHSA)? (y/n)

2. Are you registered with Compensation of Occupational Injuries and Diseases Act (COIDA)? (y/n) COIDA registration number:

3. If any of your employees will be working on DBSA’s premises or a DBSA site, please attach a copy of good standing with the Commissioner for the Occupational Injuries and Disease Act (COIDA).

Section H: Environmental Risk Management1. Do you have an Environmental Policy in place? (y/n)

2. Does your facility routinely work with any hazardous substances? (y/n)

Enclose the following documents with your application:1. An original valid TAX Clearance certificate issued by the South African Revenue Service (SARS);2. A BEE verification certificate issued by an Accredited Verification agency or Verification Agencies that are in procession

of a valid pre-assessment letter from the South African National Accreditation System will be valid. (Notice 354 of 2009)3. An original cancelled cheque or stamped letter from the bank, verifying the banking details (Please note: any

changes to bank details in the future should be furnished to us as payments are mostly done electronically);4. Copy of company/CC Registration Documents (all relevant CIPRO documentation);5. Copy of ID Documents of Directors/Owners/Members/Shareholders/Partners (where the number is such that the copies

will be voluminous, confine the copies to branches);6. Copy of latest financial statements;7. A copy of good standing with the Commissioner for the Occupational Injuries and Disease Act (COIDA).

The following information must be made available on request:1. Copies of any other registration certificate pertaining to your industry, e.g. Electrical Contractors Board (ECB);2. Copy of company Organogram, showing Holding and Subsidiary company(s), as well as operating divisions. Indicate

ownership/shareholding that this company holds in any other company(s).3. Letter from the bank confirming all bank account signatories.

Terms of this Application1. Incomplete, false or misrepresented information may result in the unsuccessful registration of this application.2. The DBSA reserves the right to verify any of the representations or references made in this application form.3. Registration on the Database does not guarantee procurement, but rather an opportunity to be invited to quote or bid

when the need arises at the DBSA.4. From time to time, where applicable suppliers will be requested to complete or update their information by request to fill in

a new form.

DeclarationI certify that the information furnished herein is correct at the time of completion. I also certify that I am duly authorised to furnish the above-mentioned information on behalf of my employer.

Name: Signature:

Designation: Date:

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