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DANNHAUSER MUNICIPALITY KZN 254

8 Church Street Telephone : 034 621 2666Private Bag X1011 Facsimile :034 621 2342

DANNHAUSER email : [email protected]

Service Provider DatabaseOriginal application must be completed and

Submitted to:

Enquiries:Mr. Yusuf NabeeTel : 034 621 2666Fax : 034 621 2342 / 086 6900 882Email : [email protected]

No Details Service Provider

Dannhauser Municipality Kzn 254

Service Provider Database8 Church Street or Private

Bag x1011Dannhauser Dannhauser

FOR OFFICIAL PURPOSE ONLY

Name of Service Provider : ________________________________

________________________________________________________

Registration No : _____________________ Date : ____________

1

mailto:[email protected]


Details1. Business Name

2. Type Of Business (Soletrader, Cc, Co)

3. Registration No (Co & Cc or Co-operative)

4. Date of Registration5. Vat Registration No6. Physical Address

7. Postal Address

8. Telephone No

9. Fax No10. Email Address

11. Website Address

12. Tax Clearance Certificate(Attach copy)

13. Proof Of Rates & Service Changes been paid (Attach Copy)

14. Satisfactory proof of Skills & Resources to execute the service to be rendered or supply of goods… (References/brochures etc. Company Profile to be attached)

Type of Business*Please tick the appropriate block

2


Public Company Ltd

Private Company (Pty) Ltd

Close Corporation CC

Sole Proprietor

Partnership

Trust

Co-operativeKindly attached signed letter of Authority by all members

Voluntary Associations

Previous Database Registration Number (if applicable)*Please ensure to attach a certified copy of the document dependent on type, e.g. Public Co, to attach certified copy of Incorporation.

Previous Business InformationDid your business exist under a previous name?If “Yes”, what was the previous business Name:

Reasons for Name Change:

Previous Names of Owners, Partners, Members or Shareholders:Name Title

Yes / No

3


Business Information*Please indicate you appropriate SectorAgricultureMining & QuarryingManufacturingElectricity, Gas & WaterConstructionRetail, Motor Trade & RepairWholesale Trade, CommercialCatering, Accommodation, OtherTransport & StorageFinance & Business ServicesCommunity, Social and Personal

Proprietors / Shareholders / Partners / Sole Proprietors / Trustees / OwnersPlease list all 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 NO DISABILITY INSTITUTION

SHAREHOLDING

4


5


Employee Details: (Make a copy and attach if more space is required)

ID No SA Citizen

Yes / No

SA Citizen before

27.04.1994

Designation (Member,

Partner etc)

% ownership/

Partner ship/trust/ interest

Male/ female

Handicapped

Y/N

HDIYes/No

Race(W/ B/I / C/

Other)

% of time

Devoted tofirm

6

Full Name ID No SA Citizen

Yes / No

SA Citizen before

27.04.1994

Capacity (Member, Partner

etc)

% ownership/

Partner ship/trust/ interest

Male/ female

Handicapped

Y/N

HDIYes/No

Race(W/ B/I / C/

Other)


7

Annexure 1 (PLEASE ENSURE THAT YOU LIST 1 MAIN

CATEGORY)Dannhauser municipality kzn 254

Supply chain management database category list

Construction Air conditioning systems Electrical ContractorsAlarm/Security systems/Access control Evacuation systemsAutodavos FencingAutomatic hanger doors General Building WorkAutomatic Sliding Doors GlazingAutomatic Sprinkle Fire Protection Systems Hauling/Heavy Equipment/TransportBrickwork/ Masonry Hot water InstallationsCabinet/Furniture Making IncineratorsCarpeting/Tiling/Floor covering Landscaping/EarthworksCeilings, partitioning & Shopfitting Lift & Escalator EquipmentCladding contracts Mechanical ContractsCooking & related systems Metalwork & Burglar BarsCompressed Air installations PaintingConcrete works PavingDemolition PlasteringPlumbingPrecast concrete ManufacturePumping InstallationsRoad marking & signageRoadworks & CleaningRoofing & WaterproofingSewage Installation/ReticulationsSteam Installations & Ancillary EquipmentSteel fabrication & ErectionStorm-water drainingWater installations/reticulationsOther (specify) ______________________________________

ServicesAccommodation Horticultural ServicesAdvertising/Public Relations HV Fault finding, Joining, TerminationsAuto Repairs & Services Insurance/Employee benefitsAuto Electrical & Hydraulic Repairs Interior/Industrial DesignBookkeepers IT Maintenance

Carpet Cleaning IT ManagementCatering/Vending/Food Supply IT NetworkingCleaning Services IT ProgrammingComputer Supplies/Services Laundry service/Dry CleaningCorporate Gifts/Clothing Locksmith servicesCopywriting Media LiaisonCourier Services Mailing/Courier ServicesCleaning Equipment/Materials Medical/Ambulance/Health CareDiesel & Petrol Engines Municipal ServicesDebt Collection Medical Equipment/InstrumentsDistribution Office MaintanceDigging of Graves Personnel ServiceEducational Services Pest Removal ServiceEntertainment Performance Management Fire extinguishers & refills Printing/Photography/Graphic DesignFire Hydrants Promotional MaterialsFood & Beverage PublishingFuneral Services Real EstateFlorist Radio Publicity / TV PublicityGarden Services Road MaintanceHandy man Recruitment AgenciesSafety & Security services Safety & Security Access controlServicing HV & LV switchgear/Transformers Site CleaningSolid Waste Disposal Telephone & Data Line MaintanceTraining & DevelopmentOther (Specify) _______________________________________________________________________________________________________________________________________________________________________________________

Professional ServicesAccountants/Financial Advisory Services OHS ConsultantsArchitects Organisational Development ConsultantsAttorneys/Legal Services PharmaciesArchival Services Consultants Pre-employments Assess. ConsultantsBusiness Information Management Project ManagersConsulting Engineers (Geotechnial) Quantity SurveyorsConsulting Engineering (civil/structure) StatisticiansConsulting Engineers (Electrical) TeachersConsulting Engineers (Mechanical) Town PlannersConsulting Engineers (Multidisciplinary) Training Providers

Contractors Translation ServicesEDMS Consultants EAP ConsultantsEconomists Medical PractionersIndustrial Relations Consultans Job Description Consultants Legal Compliance Consultants Land SurveyorsOther (Specify) ___________________________________________________________________________________________________________________________________________________________________________________

wholesalers / TradersAutomotive parts Fire ExtinguisherAir Pollution Measuring Equipment Fire Protection & DetectionBooks Floor CoveringsBuilding Materials & Hardware Food SuppliesBatteries FertilisersCleaning Supplies/Chemicals/Pesticides Fuel SuppliesClothing FurnitureComputer Equipment & Software FencingCurtains Food for game animalsConsumables Generating setsDomestic Appliances & Groceries Health Safety & Environmental SupplyElectrical Supplies & Equipment IT Hardware & SoftwareIndustrial Catering Equipment Linen, Pillows & BlanketsLaundry Equipment Medical Supplies & EquipmentMedicines NGO’s / NBO’sOffice Consumables Office EquipmentPaint Supplies Paper & StationeryRecreational Supplies Refrigeration & Air ConditioningRefuse Bulk Containers Protective Clothing / UniformsRadio / Radio Eqipment Supply plants, flowers & SeedsToilet paper wrapped / Unwrapped Traffic Signs/MaterialsVehicle Workshop EquipmentVehicles, Equipment, trailers & tractorsOther (Specify) _______________________________________________________________________________________________________________________________________________________________________________________

Annexure 2 – Certified Banking Details FormThis form needs to be completed and certified by the appropriate Banking Institute and attached to the registration Form.

Name of Banking Institute: _________________________________

Branch Name _________________________________

Branch Code _________________________________

Town/City _________________________________

Bank Account Number _________________________________

Name of Account Holder _________________________________Name under which the account is operated, this needs to be same as

business name

Type of account e.g. cheque _________________________________

BANK STAMP

Received & Stamped By ______________________________(Name in Block letters)

Signature ______________________________

Date ______________________________

Annexure 3 – Required Documentation check listPlease ensure that all listed documentation below is attached (where applicable) to the registration form

ALL documentation to be provided in its original format

DOCUMENT NAME ATTACHED

Original Tax Clearance Certificate

Company Registration Certificate

Company Resolution of Signatories

Original / Certified copy of “Letter of Good Standing” from

Workmen’s Compensation Commissioner or its Agent

Most recent municipal accounts for your business location or your

personal residence account i.e. rates, water, refuse, electricity (if

applicable) levy confirmation registration letter.

Financial Documentation

Staff Listing

BEE Certificate

OWNER / OWNERS DETAILS

SURNAME :

____________________________________________

FIRST NAME/S :

____________________________________________

ID NO :

____________________________________________

PHYSICAL ADDRESS :

____________________________________________

____________________________________________

POSTAL ADDRESS :

____________________________________________

____________________________________________

TEL NO :

____________________________________________

CELL NO :

____________________________________________

FAX NO :

____________________________________________

EMAIL ADDRESS :

____________________________________________

OWNERS BANKING DETAILS:

1. Correct Account Name : _______________________________

2. Name of Bank : _______________________________

3. Branch Code :

_______________________________

4. Account Number : _______________________________

5. Type of Account : _______________________________e.g. cheque, current, savings

Verification of information supplied relating to references that the Applicants / Business may apply for.I/We, the undersigned, who warrants that I/we are duly authorised to do so on behalf of the supplier, certifies that the information supplied in terms of this documentation including the Annexure(s) with additional information, is correct and accurate and acknowledges that:-

1. The supplier will be required to furnish documentary proof of the information relating to preferences, if required to do so.

2. If the information supplied is found to be incorrect, then Dannhauser Municipality may, in addition to any other remedies it may have: Disqualify the supplier/contractor for a particular bid/contract/project it may be

considered for, or which had been awarded to the supplier/contractor; Recover from the supplier/contractor for all costs, losses or damages incurred

or sustained by Dannhauser Municipality as a result of breach of contract; Cancel the contract and claim any damages which Dannhauser Municipality

may suffer by favourable arrangements after such cancellation and / or; De-register the supplier registered on the Supplier Database

SIGNED ON THIS _______ DAY OF _____________________ 20________

AT: ___________________________

______________________ _________________________Name of Representative Signature of Authorised

Representative

________________________________________________________Suppliers Name

MBD 4

DECLARATION OF INTEREST

1. No bid will be accepted from persons in the service of the state¹.

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

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 has

acknowledged that he/she has no obligation to affirming, that he/she regards the

affirmation to be binding on his/her conscience.

___________________________________ Commissioner of oaths

__________________________________________________ ___________________________________Name in Block letters Capacity

_________________________________________________________________________________________________Business Address

Area : _______________________________________________________________________________

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.

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

3.6.1 If yes, furnish particulars. ….………………………………………………………………………

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

¹MSCM 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(f) an employee of Parliament or a provincial legislature.(g) Exemption from regulation 44 of the Supply Chain Management Regulations

I. All municipalities and municipal entities are subject to sub clauses (2) and (3), exempted from regulation 44 of the Supply Chain Management Regulation prohibits municipalities and municipal entities from making awards to a persons on any of the following grounds

That person is a non-executive member of the Board of Directors or a municipal entity or

That a person is not a natural person and any of its directors, managers principal shareholders or stakeholders is a non-executive member of the Board of Directors of a municipal entity

II. The exemption contained in sub clause (1) does not apply to the municipal entity on whose Board of Directors a person referred to in paragraph (i) or a director, manager principal shareholder referred to in the exemption contained in sub clause (i) is subject to the following conditions

i. in the case of a bidder who is a natural person, whether that bidder serves on the Board of Directors of any municipal entity and if so-

a. Whether that person serves as an executive or non-executive of the Board and

b. The name of the relevant municipal entityii. in the case of a bidder which is not a natural person whether any director manager

principal shareholder or stakeholder of that bidder serves on an executive on the Board of Directors of any municipal entity and if so-

a. Whether that person serves as an executive or non-executive of the Board and

b. The name of the relevant municipal entityiii. a disclosure in terms of paragraph (i) by the successful bidder must be placed on

the website of the municipality or municipal entity making the award andiv. the notes to the financial statements of a municipality or municipal entity must

disclose particulars of any award to a person by that municipality or municipal entity which would have been prohibited in terms of regulation 44 if it were not for the exemption contained in sub clause paragraph (ii) serves as a member, and that municipal entity remains fully bound by regulation 44

------------------------------------------------------------------------------------------------------------------------------------------------

3.7 Have you been in the service of the state for the past twelve months? YES NO

3.7.1 If yes, furnish particulars.………………………...………………………………………………

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

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?

YES NO

3.8.1 If yes, furnish particulars……………………………………………………………………….

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

3.9 Are you, aware of any relationship (family, friend, other) between any other bidder and any persons in the service of the state who may be involved with the evaluation

and or adjudication of this bid? YES NO

3.9.1 If yes, furnish particulars……………………………………………………………………….

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

3.10 Are any of the company’s directors, trustees, managers, principle shareholders or stakeholders in service of the state?

YES NO

3.10.1 If yes, furnish particulars……………………………………………………………………..

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

3.11 Are any spouse, child or parent of the company’s directors trustees, managers, principle shareholders or stakeholders in service of the state?

YES NO

3.11.1 If yes, furnish particulars……………………………………………………………………..

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

3.12 Does any of the company’s directors managers principle shareholders serves as an executive or non-executive member or the board of directors of a municipality or municipal entity?

YES NO

3.12.1 If yes, furnish particulars………………………………………………………………………

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

CERTIFICATION

I, THE UNDERSIGNED (NAME)____________________________________________________________ CERTIFY THAT THE INFORMATION 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 ______________________________________

COMPANY NAME ______________________________________

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