suppliers database registration forms

Suppliers Database Registration Forms

DELIVER TO:

ENQUIRIES

FOR OFFICE USE ONLY

UMGUNGUNDLOVU ECONOMIC DEVELOPMENT AGENCY RECEPTION

191 BURGER STREET PIETERMARRITZBURG

3200

T: 033 342 3396

E: [email protected]

W: www.umeda.co.za

mailto:[email protected]

2

INTRODUCTION

The Supplier Database Registration Form was specifically designed to provide for. the registration of suppliers on the

uMgungundlovu Economic Development Agency.

Suppliers Database,

In order to ensure that suppliers are considered legitimate, dissipative that the following guidelines are adhered to.

GUIDELINES

Applicants must complete pages 2 to 13, where applicable. Failure by an applicant to provide ALL the

prescribed information and documents required will result in non-registration. If the information required

is not applicable to your business; clearly insert the symbols "N / A" in the appropriate space. All

mandatory fields marked by two asterisks ** are to be filled in. If the space provided is left blank and or

mandatory fields are not filled in, it will be regarded as information that is still outstanding and you WILL

NOT be registered. Only black ink is to be used when filling in the form.

Applicants are advised that only ORIGINAL Supplier Database Registration Form or PHOTOSTAT copies thereof will

be processed. Any document: that has been retyped or redrafted will be disregarded and returned to the applicant.

It is imperative that only supporting documents with an ORIGINAL signature be submitted.

All signatures to the document must be commissioned by an authorised Commissioner of Oaths. Failure to do so will

result find the applicant not qualifying for registration.

A supplier registered on the Suppliers Database MUST notify uMgungundlovu Economic Development Agency of any

changes to information provided in the initial Supplier Database Registration Form, as captured onto the Suppliers

Database.

Failure to do so may result in such a supplier being removed from the Suppliers Database and/or the cancellation of

contracts awarded to the supplier; based on misrepresentation.

Suppliers providing information incorrectly or fraudulently in their Supplier Database Registration' Form will: be

disqualified from bidding and removed from the Suppliers Database, in addition to action the Province may institute

against such a supplier. Furthermore/in the event of the Province being prejudiced financially; it reserves the right to

take legal action against the supplier.

Any alterations made by the supplier to its own information inserted on this document, must be initialled by the

supplier. The use of correcting fluid 'is prohibited and the use thereof will 'lead to non-registration of the applicant

business/supplier.

It remains the responsibility of the supplier to ensure that the information is updated in the Suppliers Database.

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SECTION A: COMPANY INFORMATION

1. Business particulars **

2. Financial information**

The following information must be filled in by the applicant. Failure to submit ALL the required information. may lead to

non-registration of the applicant's business.

PLEASE USE BLOCK LETTERS.

Your current database registration numbed (Database number)

Name of your business as registered with the registrar

of companies

Trading as

Holding company

Registration number of Company/CC/Trust/Fund number

Business Postal address

Business Physical address

Telephone number

Cellular phone number

E-mail address

Website

Preferred language IsiZulu

Contact person (Full Name & Surname)

Physical Location of Head

Office (if applicable)

Code

C O D E T E L E P H O N E

English Afrikaans

Code

Name of bank account holder

Type of bank account Current

Bank branch number (at least six numbers)

Bank account number

N.B: A certified copy of latest bank statement or original cancelled cheque or original letter from your bank must be

attached.

1 Savings 2 Transmission 3

4

3.Indicate the value of the below stated based on the latest financial statement **

UIF number

Compensation commissioner registration number

Income tax reference number

PAYE number

Financial year-end

VAT registration number

Tax clearance certificate issue date

Tax clearance expiry date

N.B: A certified copy of a tax clearance certificate must be supplied

Total fixed assets at book value (e.g. land, buildings, plants, equipment)

Vehicles at book value

Number of vehicles

Average stock on hand

Cost of goods produced annually

Quantity produced annually

Units of measure (e.g. tons, kilolitres)

Total current assets (e.g. stock, debtors, cash)

Total current liabilities (e.g. creditors, bank overdraft)

R

R

R

R

R

4. Municipalities **

Please clearly indicate, with an ‘X’, the District Municipality/s where your business operates.

7

D D M M

4

D D M M Y Y Y Y

D D M M Y Y Y Y

eThekwini Municipality (DC 20)

uGu Municipality (DC 21)

uMgungundlovu (DC 22)

uThukela Municipality (DC 23)

uMzinyathi Municipality (DC 24)

Sisonke Municipality (DC 47)

Amajuba Municipality (DC25)

Zululand Municipality (DC 26)

uMkhanyakude Municipality (DC 27)

uThungulu Municipality (DC 28)

iLembe Municipality (DC 29)

5

5. Previous business information (if applicable)

6. Previous experience (if applicable)

Did your business exist under a different name previously?

If “yes” what was the previous business name?

What was the previous database registration number (database number)?

Yes OR No

List the last three (3) contracts awarded to you (the supplier) or other previous experience related to your core business

CONTRACT 1

Employer/

Department

Contact person

Initials

Telephone number

Was the project completed successfully? (Mark applicable block with an “X”)

What year was the project initiated?

What was the contract value?

Surname

C O D E - T E L E P H O N E

OR No Yes

Y Y Y Y

R

CONTRACT 2

Employer/

Department

Contact person

Initials

Telephone number




CONTRACT 3

Employer/

Department

Contact person

Initials

Telephone number




Surname


Yes

OR No

Y Y Y Y

R

Surname


Yes OR No

Y Y Y Y

R

6

SECTION B: CLASSIFICATION OF BUSINESS

1. Type of business **

2. Products & Services**

Please mark with an 'T X" the block applicable to your business or firm AND attach the relevant certified copy

A. Public Company LTD

B. Private Company (PTY) LTD

C. Close Corporation CC

D. Incorporated

E. Sole Proprietor

F. Partnership

G. Trust

H. Co-Operative

I. Welfare organisation

Certified copy of certificate incorporation (CM 1)

Certified copy of certificate of incorporation (CM 1)

Certified copy of CK 1 document and CK 2 applicable

Certified Copy of certificate of incorporation (CM 1 and CM 29)

Certified copy of Identity Document

Certified copy of partnership agreement

Certified copy of trust document

Certified copy of proof of registration with the directorate Co-Operatives

Certified copy of constitution

Total Gross Asset value (fixed property excluded)

Annual turnover

Number of employees

R

R

In order to assist with the classification of. suppliers, please •indicate the industrial sector related to the goods / services that you supply (Only a maximum of FOUR industrial- sectors may be selected), If the supplier selects more than FOUR (4) Industrial Sectors, only the

FIRST FOUR will be considered).

Please mark with an "X" the appropriate block to clearly indicate the industrial sector related to the goods and services that you

supply

Finance and Business service

Banking

Insurance

Investments

Exchanges

Legal service

Securities broker

Credit institutions

Business & management consultant

Chattered accountant

Architects & quantity surveyors

Engineering

Other (Please Specify)

7

Community, social & personal services

Collectibles & awards

Fitness equipment

Water sport equipment

Janitorial equipment

Sports equipment & accessories

Cleaning &janitorial equipment

Field & court sports equipment

Gymnastics & Boxing equipment

Camping, outdoor equipment & accessories

Fishing & hunting equipment

Winter sports equipment

Target, table games & equipment

Water, wastewater treatment supply & disposal

Industrial laundry & dry-cleaning equipment

Recreation, playground, swimming, spa equipment & supplies

Other (please specify)

Mining & Quarrying

Fuels

Elements & gases

Gaseous fuels & additives

Fuel for nuclear reactors


Oil, gas drilling & operating equipment

Well drilling & operating equipment

Oil, gas & Exploration equipment

Lubricants, Oils, greases & anti corrosives

Mining, quarrying machinery & equipment

Transport, storage and communication

Non-motorized cycles

Aircraft

Software

Marine transport

Railway, trainway machinery & equipment

Data voice, multimedia network equipment & accessories

Components for information technology, telecommunications

Aerospace systems, components & equipment

Other (Please specify)

Spacecraft

Transportation service equipment

Computer equipment & Accessories

Hydraulic machinery & equipment

Communications devices & accessories

Transportation components & systems

Structural building products

Automotive speciality tools

8

Catering and accommodation and other trade

Edible Oils & fats

Meat & Poultry products

Sea food

Hotels

Lodges

Vending machines

Museums

Art galleries

Media

Film

Audio, visual presentation & composing equipment

Chocolate sugars, sweeteners, confectionary products


Bread & bakery products

Cereal & pulse products

Dairy products & eggs

Camps

Bed & breakfast

Gambling or wagering equipment

Zoological gardens

Photographic filmmaking suppliers

Botanical gardens

Music

Fruits, vegetables, nuts & seeds

Prepared & Preserved foods

Restaurant

Liquor outlets

Institutional food services equipment

Amusement & recreational services

Photographic & recording media

Printing & publishing equipment

Photographic video equipment

Agricultural, forestry and fishing

Live animals

Domestic pet products

Pest control products

Agricultural, forestry, landscape material & equipment

Gymnastics & boxing equipment


Animal feed

Animal containment & habitats

Floricultures & silviculture’s

Seeds, bulbs, seedings & cutting.

Saddlery & hams goods

Fertilizers, plant nutrients & herbicides

Fishing & aquaculture equipment

Electricity, gas and water

Power sources

Fluid & gas distribution

Batteries, generator & kinetic power transmission

Atomic, nuclear energy machinery & equipment


Electrical wire, cable & hamess

Heating, ventilation & air circulation

Power generation

Industrial filtering & prefinalisation

Industrial pumps & compressors

9

Construction

Roads & landscape

Insulation

Plumbing fixtures

Hand tools

Heavy construction machinery & equipment

Pneumatic machinery & equipment

Construction & maintenance support material


Prefabricated structures

Permanent structures

Structural materials & basic shapes

Hydraulic machinery & equipment

Doors, windows & glass

Interior finishing materials

Structural building products

Automotive speciality tools

Wholesale trade, commercial agents and allied services

Durable goods


Non-Durable goods

Retail, motor trade and repair service

Petrol stations

Repair service

Motor vehicles

Other

General merchandise stores

Apparel & accessory stores

Vehicle bodies & trailers

Furniture, furnishing &equipment stores

Fleet management

Manufacturing

Packing supplies

Paper materials

Wound care products

Adhesives & sealants

Lamps & lights

Paper products

Electronic hardware & components


Industrial refrigeration

Machined raw stock

Mouldings

Paints, primes & finishers

Dyeing & tanning extracts

Workshop machinery, equipment & suppliers

Machine made parts

Metal waste scrap

Packaging materials

Housing, cabinets & casing

Fabricated bar stock assembles

Light weapons & ammunition

Laboratory supplies & fixtures

10

SECTION C: OWNERSHIP INFORMATION**

Full name/ Name of business

SA Identity number/Business Registration No.

SA Citizen before 27 April 1994 YES / NO

Capacity: Member/ Partners/Proprietor /Shareholder/ Trustee/ Beneficiary

Ownership/ Partnership/Trust/interest %

Gender

F / M

Disability

YES / NO

% of time devoted to the firm

Race (Black; White; Indian; Coloured

; Other)

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

1. List all persons/entities who are Owners in the business / trust and indicate their involvement in the management / operations of the

business / trust.

Proof of disability provided by a recognised related institution, in the case of handicapped persons, must be supplied. If there is

insufficient space, kindly attach a copy / copies of this page to this ZNT 31, signed by the same person who signs on behalf of the

business/ trust.

11

Name of owner

Name of other business

Registration number of business

Position held

Ownership %

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

2. Please indicate any owner who has a controlling ownership interest in another business

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3. Business management **

Identify by name the Historically Disadvantaged Individual (HDI) status and the length of services of the individuals in the

business. Include owners and non-owners responsible for the day-to-day Management and Business decisions.

Cheque signing

Initials

Number of years in service

Surname

Y Y

Race (Mark applicable block with an “X”)

Other (please Specify

White Black Indian Coloured

Signing & co-signing for loans

Initials


Surname

Y Y




Business financing (Overdraft, lease agreement)

Initials


Surname

Y Y




Sureties

Initials


Approval of major purchase or acquisitions

Initials


Surname

Y Y




Contract signing

Initials


Surname

Y Y

Race (Mark applicable block with an “X”



Surname

Y Y

Race (Mark applicable block with an “X”



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4. Verification of Information **

I/ We, the undersigned; Miho warrants that he/she is duly authorised to do so- on behalf of the supplier;- certifies that the

information supplied in terms of this document Supplier Database Registration Form including the annexure/ s with additional

information/ is correct and accurate and acknowledges that:

A. The supplier will be required to furnish documentary-proof, of the information- relating to preferences requested to do so.

B. If the information supplied 'is found to being correct, then the Province addition to any remedies it may have:

i. Disqualify the supplier/contractor for a bid/contact/project it may be considered for, or which had been awarded to the

supplier/contractor.

ii. Recover from the supplier/contractor all costs, flosses or damages incurred or sustained by the Province as a result of

breach. of the contract.

iii. Cancel the contract and claim any damages which the Province 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 before The Commissioner of Oaths: (Supplier representative)

Initials

Signature

Signed at

Supplier Name

Surname

Date Signed D D M M Y Y Y Y

Signed and affirmed before me at (Commissioner)

Commissioner of oaths signature

Date Signed D D M M Y Y Y Y

Initials

Surname

Business Physical Address

Postal code

Capacity

Area

OFFICIAL STAMP

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SECTION D: DECLARATION OF INTEREST

1. No tender/quotation 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 an invitation to tender or quotation. In view of possible allegations of

favouritism, should the resulting tender, or part thereof, be awarded to persons connected with or related to

persons in service of the state, it is required that the Vendor or their authorized 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 this

Application:

3.1 Full Name (Vendor or Authorised Representative as mentioned above)

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

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

3.6.1 If so, furnish particulars:

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

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

3.7 Have you been in the service of the state for the Yes No

past twelve months?


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

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

3.8 Do you have any relationship (family, friend, other) Yes No

with persons in the service of the state and who

may be involved with the evaluation and/or

adjudication of this tender?


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

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

3.9 Are you aware of any relationship (family, friend, Yes No

other) between a tenderer and any persons in the

service of the state who may be involved with the

evaluation and/or adjudication of this tender?

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

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

3.10 Are any of the company’s directors, managers, Yes No principle shareholders or stakeholders in service of the state?


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

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

3.11 Are any spouse, child or parent of the company’s Yes No directors, managers, principle shareholders or stakeholders in service of the state?


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

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

*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.

CERTIFICATION

I, the undersigned (name)

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

certify that the information furnished on 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 TENDERER

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SECTION E: CHECKLIST

Please use this checklist as confirmation that ALL the required Information/ Documents have been submitted. Please

indicate with an “X”.

Supplier For official use

The following Documents have been attached:

Original Tax Certificate

Certified copy of the Company Registration Certificate

Proof of: Banking Details

The following mandatory fields have been completed:

Business Particulars Municipalities

Financial Information

Type of Business

Products & Services

Ownership Information

Business Management

Verification of Information

Declaration of Interest

FOR OFFICIAL USE

I acknowledge that this form has been checked by me, and all the required Information/Documents have been

furnished.

Signed

Initials

Surname

Date D D M M Y Y Y Y

UMEDA SCM Database Registration: Modified on 18th March 2021.