8 Church Street Telephone : 034 621 2666

DannhauserMunicipality kzn254

8 Church Street Telephone : 034 621 2666

Private Bag X1011 Facsimile :034 621 3114

DANNHAUSERemail :

3080 email :

Service Provider Database

Original application must be completed and

Submitted to:

Enquiries:

Mr. Yusuf Nabee

Tel:034 621 2666

Fax: 034 621 2342 / 086 6900 882

Email :

No / Details / Service Provider Details
1. / Business Name
2. / Type Of Business (Soletrader, Cc, Co)
3. / Registration No (Co & Cc or Co-operative)
4. / Date of Registration
5. / Vat Registration No
6. / Physical Address
7. / Postal Address
8. / Telephone No
9. / Fax No
10. / 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

Public Company Ltd
Private Company (Pty) Ltd
Close Corporation CC
Sole Proprietor
Partnership
Trust
Co-operative
Kindly 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 Information

Did 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

Business Information

*Please indicate you appropriate Sector

Agriculture
Mining & Quarrying
Manufacturing
Electricity, Gas & Water
Construction
Retail, Motor Trade & Repair
Wholesale Trade, Commercial
Catering, Accommodation, Other
Transport & Storage
Finance & Business Services
Community, Social and Personal

Proprietors / Shareholders / Partners / Sole Proprietors / Trustees / Owners

Please 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 / SHARE
HOLDING

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 / Handi
capped
Y/N / HDI
Yes/
No / Race
(W/ B/
I / C/
Other) / % of time
Devoted to
firm

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

Full Name / ID No / SA Citizen
Yes / No / SA Citizen before 27.04.1994 / Designation (Member, Partner etc) / % ownership/ Partner ship/trust/ interest / Male/ female / Handi
capped
Y/N / HDI
Yes/
No / Race
(W/ B/
I / C/
Other) / % of time
Devoted to
firm

Annexure 1 (PLEASE ENSURE THAT YOU LIST 1 MAIN CATEGORY)

Dannhauser municipality kzn 254

Supply chain management database category list

Construction

Air conditioning systemsElectrical Contractors

Alarm/Security systems/Access controlEvacuation systems

AutodavosFencing

Automatic hanger doorsGeneral Building Work

Automatic Sliding DoorsGlazing

Automatic Sprinkle Fire Protection SystemsHauling/Heavy Equipment/Transport

Brickwork/ MasonryHot water Installations

Cabinet/Furniture MakingIncinerators

Carpeting/Tiling/Floor coveringLandscaping/Earthworks

Ceilings, partitioning & ShopfittingLift & Escalator Equipment

Cladding contractsMechanical Contracts

Cooking & related systemsMetalwork & Burglar Bars

Compressed Air installationsPainting

Concrete worksPaving

DemolitionPlastering

Plumbing

Precast concrete Manufacture

Pumping Installations

Road marking & signage

Roadworks & Cleaning

Roofing & Waterproofing

Sewage Installation/Reticulations

Steam Installations & Ancillary Equipment

Steel fabrication & Erection

Storm-water draining

Water installations/reticulations

Other (specify) ______

Services

AccommodationHorticultural Services

Advertising/Public RelationsHV Fault finding, Joining, Terminations

Auto Repairs & ServicesInsurance/Employee benefits

Auto Electrical & Hydraulic RepairsInterior/Industrial Design

BookkeepersIT Maintenance

Carpet CleaningIT Management

Catering/Vending/Food SupplyIT Networking

Cleaning ServicesIT Programming

Computer Supplies/ServicesLaundry service/Dry Cleaning

Corporate Gifts/ClothingLocksmith services

CopywritingMedia Liaison

Courier ServicesMailing/Courier Services

Cleaning Equipment/MaterialsMedical/Ambulance/Health Care

Diesel & Petrol EnginesMunicipal Services

Debt CollectionMedical Equipment/Instruments

DistributionOffice Maintance

Digging of GravesPersonnel Service

Educational ServicesPest Removal Service

EntertainmentPerformance Management

Fire extinguishers & refillsPrinting/Photography/Graphic Design

Fire HydrantsPromotional Materials

Food & BeveragePublishing

Funeral ServicesReal Estate

FloristRadio Publicity / TV Publicity

Garden ServicesRoad Maintance

Handy manRecruitment Agencies

Safety & Security servicesSafety & Security Access control

Servicing HV & LV switchgear/TransformersSite Cleaning

Solid Waste DisposalTelephone & Data Line Maintance

Training & Development

Other (Specify)______

______

Professional Services

Accountants/Financial Advisory ServicesOHS Consultants

ArchitectsOrganisational Development Consultants

Attorneys/Legal ServicesPharmacies

Archival Services ConsultantsPre-employments Assess. Consultants

Business Information ManagementProject Managers

Consulting Engineers (Geotechnial)Quantity Surveyors

Consulting Engineering (civil/structure)Statisticians

Consulting Engineers (Electrical)Teachers

Consulting Engineers (Mechanical)Town Planners

Consulting Engineers (Multidisciplinary)Training Providers

ContractorsTranslation Services

EDMS ConsultantsEAP Consultants

EconomistsMedical Practioners

Industrial Relations ConsultansJob Description Consultants

Legal Compliance ConsultantsLand Surveyors

Other (Specify) ______

______

wholesalers / Traders

Automotive partsFire Extinguisher

Air Pollution Measuring EquipmentFire Protection & Detection

BooksFloor Coverings

Building Materials & HardwareFood Supplies

BatteriesFertilisers

CleaningSupplies/Chemicals/PesticidesFuel Supplies

ClothingFurniture

Computer Equipment & SoftwareFencing

CurtainsFood for game animals

ConsumablesGenerating sets

Domestic Appliances & GroceriesHealth Safety & Environmental Supply

Electrical Supplies & EquipmentIT Hardware & Software

Industrial Catering EquipmentLinen, Pillows & Blankets

Laundry EquipmentMedical Supplies & Equipment

MedicinesNGO’s / NBO’s

Office ConsumablesOffice Equipment

Paint SuppliesPaper & Stationery

Recreational SuppliesRefrigeration & Air Conditioning

Refuse Bulk ContainersProtective Clothing / Uniforms

Radio / Radio EqipmentSupply plants, flowers & Seeds

Toilet paper wrapped / UnwrappedTraffic Signs/Materials

VehicleWorkshop Equipment

Vehicles, Equipment, trailers & tractors

Other (Specify)______

______

Annexure 2 – Certified Banking Details Form

This 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 list

Please 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

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:-

The supplier will be required to furnish documentary proof of the information relating to preferences, if required to do so.
If the information supplied is found to be incorrect, then DannhauserMunicipality 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 DannhauserMunicipality as a result of breach of contract;
Cancel the contract and claim any damages which DannhauserMunicipality 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 RepresentativeSignature of Authorised Representative

______

Suppliers Name