Database Registration Form

A2601/3 Bongimfundo Street

Private Bag X4012

SIYABUSWA

0472

Tel: 013 973 1101/1390

Database Registration Form

SECTION A

Name:

Surname:

Position:

Cell:

Fax:

Email:

Preferred Method Of

Communication (Please tick): Email Fax Post

SECTION B

New Company Profile

Company Details

Name:

Trading Name:

Company Reg No:

Translated Name:

HDI: YES NO

Did the business exist under

another name previously? YES NO

If "yes" what is the name:

Reason For Change:

Top of Form

Registration Date:

Business Type:CLOSE CORPERATION

PRIVATE COMPANY (PTY) LTD

PUBLICK COMPANY

SECTION 21 COMPANY

CONSORTUIM OR JOINT VENTURE

PARTNERSHIP

SOLE TRADE OR PROPREITOR

TRUST

Water Acc No:

Financial Details

Annual Turnover:

Financial Year End (Month):

Contact Details

Telephone:

Fax:

Website:

Postal Address:

Code:

Registered Office Address:

Code:

Location (Municipality):

Business Classification

Classification (Please tick):MICRO

VERY SMALL

SMALL

MEDUIM

COMMODITIES(please do not choose more than 6 commodities, only 6 commodities will be considered)

CODE / COMMODITY_DESCRIPTION / CODE / COMMODITY_DESCRIPTION
0001 / Accounting & Bookkeeping / 0109 / E250.3 ReticMaster
0002 / Accounting Systems Software / 0110 / Stadia & High Mast Floodlighting
0003 / Architects / 0111 / Stadia & High Mast Floodlighting
0004 / Advertising / 0112 / Decorative & Festive Lighting
0005 / Agricultural Services & Equip / 0113 / Street Lighting - Design & Pro
0006 / Air Conditioner Repairs / 0114 / Street Lighting Maintenance &
0007 / Accommodation / 0115 / High & Medium Voltage Network
0008 / Accounting Services / 0116 / HV Overhead Head Transmission
0009 / Fertiliser / 0117 / High Voltage Technical & Safet
0010 / Minor Structures / 0118 / Medium & Low Voltage Technical
0011 / Major Structures / 0119 / Transformers & Miniature Subst
0012 / Recreational & Sporting Facili / 0120 / Streetlight Poles
0013 / Architectural Maintenance / 0121 / Streetlights Fittings/Floodlig
0014 / Low Cost Housing / 0122 / General Electrical Spares/Prod
0015 / Auditing Services / 0123 / Medium Voltage Circuit Breaker
0016 / Repair and supply of Tyres / 0124 / High Voltage Circuit Breakers
0017 / Batteries / 0125 / Cables & Overhead Conductors
0018 / Parts / 0126 / High-Mast Lights
0019 / Panel Beating / 0127 / Electricity Energy Meters
0020 / Auto electrical / 0128 / Low Voltage Panels
0021 / General mechanical work / 0129 / Medium & High Voltage Switchge
0022 / Oil / 0130 / Quality of Supply Equipment
0023 / Fuel / 0131 / Load Control Equipment
0024 / Other: please provide details / 0132 / Bridges
0025 / Supply of new vehicles / 0133 / Reinforced Concrete Structures
0026 / Supply of Bitumen & Emulsions / 0134 / Pre-stressed Concrete Structur
0027 / Supply of hot bituminous aspha / 0135 / Water Retaining Structures
0028 / Clay Products / 0136 / Subsurface Structures includin
0029 / Masonry Products / 0137 / Structural Remedial Works & Ma
0030 / Catering Services / 0138 / Timber Structures
0031 / Bagged Cement / 0139 / Masonry Structures
0032 / Readymix Cement / 0140 / Structural Steel Structures
0033 / Lime for soil stabilisation / 0141 / Marine Structures
0034 / Herbicides / 0142 / Engineering ¿ Traffic
0035 / Chlorine / 0143 / Community Facilitation & Parti
0036 / Liquefied Gas (LPG) / 0144 / Transportation Planning
0037 / Compressed oxygen / 0145 / Traffic Management
0038 / Other: please provide details / 0146 / Traffic Operations
0039 / Fax machines / 0147 / Public Transport Planning
0040 / Telephone systems / 0148 / Urban Traffic Control
0041 / Mobile Phones / 0149 / Related IT
0042 / Radio Telephones / 0150 / Traffic Survey / Data Collecti
0043 / Repairs of communication devic / 0151 / Transportation Policy
0044 / Precast reinforced Concrete ma / 0152 / Transport Economics
0045 / Precast Concrete kerbs, paving / 0153 / Demography
0046 / Concrete Pipes / 0154 / Public Relations & Graphics
0047 / Courier Services / 0155 / Transport Modelling
0048 / Strategic Planning / 0156 / Environment Management Systems
0049 / Integrated Development Plannin / 0157 / Environmental Impact Assessmen
0050 / Community Facilitation & Parti / 0158 / Ecological Surveys
0051 / Social Economic Planning & Res / 0159 / Environmental Planning
0052 / Property Development Economics / 0160 / Environment Auditing
0053 / Economic Feasibility Studies / 0161 / Environmental Policy
0054 / Land Use Management Systems / 0162 / Enviromental Law
0055 / Land Use Data Collection (Fiel / 0163 / Other: please provide details
0056 / Spatial Analysis / 0164 / Supply of materials
0057 / Urban Spatial Economics / 0165 / Installation of Fencing
0058 / Layout Planning / 0166 / Curtains/Blinds
0059 / Planning Policy & Legal / 0167 / Carpets
0060 / Land Use Transport Planning / 0168 / Light Fittings
0061 / Public Housing & In-site Upgra / 0169 / Software and software developm
0062 / Minor Roads - Urban / 0170 / System analysis and design
0063 / Major Roads - Arterials / 0171 / Land Information Systems
0064 / Road Maintenance/Rehabilitatio / 0172 / Geological studies and investi
0065 / Hydraulic Engineering (Pipes N / 0173 / Foundations - minor structures
0066 / Stormwater Maintenance System / 0174 / Foundations - major structures
0067 / Catodic Protection / 0175 / Other: please provide details
0068 / Recreational & Sporting Facili / 0176 / General hardware & supplies
0069 / Pavement Design - Roads / 0177 / Hire Plant & Equipment
0070 / Pavement Design - Road mainten / 0178 / Vehicle Hire
0071 / Flood Hydraulic studies / 0179 / Supply of plants
0072 / Catchment Management / 0180 / Computers, Laptops, Printers
0073 / General Air Conditioning & Mec / 0181 / Software suppliers
0074 / Compressed Air, Gas and Vacuum / 0182 / Software developers
0075 / Cranes & Hoists / 0183 / Insurance service providers
0076 / Specialised air conditioning / 0184 / Land Survey
0077 / Acoustics & Sound proofing / 0185 / Engineeering survey
0078 / Metallurgical/CorrosionEnginee / 0186 / Sectional Title
0079 / Fire Protection Engineering / 0187 / Provision of legal services
0080 / Lifts / 0188 / Meters - Water
0081 / General refrigeration / 0189 / Meters - Electric
0082 / Specialised refrigeration / 0190 / Tables, Chairs, cabinets etc
0083 / General lighting and earthing / 0191 / Photocopiers
0084 / Floodlighting installation / 0192 / Laminating machine
0085 / Building reticulation / 0193 / Other: please provide details
0086 / Power installations / 0194 / Paint Suppliers
0087 / Fire Detection and alarm syste / 0195 / Plumbing Contractors
0088 / Building evacuation systems / 0196 / Plumbing Supplies
0089 / Telephone & Comunication insta / 0197 / Printers
0090 / Security installations / 0198 / Supply of Refuse Bags
0091 / Emergency power installations / 0199 / Refuse containers, skips and b
0092 / Public Address Systems / 0200 / Clothing
0093 / Lightning Protection Systems / 0201 / Hard Hats
0094 / Closed circuit TV and Radio In / 0202 / Boots
0095 / Standby Generator installation / 0203 / Traffic Signs
0096 / Telemetry systems / 0204 / Road Signs
0097 / Flow Gauges / 0205 / Street Name signs
0098 / Overhead high voltage transmis / 0206 / Stationery suppliers
0099 / High Voltage Substation - plan / 0207 / Valuation service provider
0100 / HV Cable - Planning, Design & / 0208 / Building Works
0101 / High & Medium Voltage Network / 0209 / Alterations,restorations & red
0102 / Medium & Low Voltage Reticulat / 0210 / Basic quantity surveying servi
0103 / Low Voltage Service Connection / 0211 / Civil engineering works
0104 / Medium & Low Voltage Reticulat / 0212 / Electrical engineering works
0105 / Medium & Low Voltage Reticulat / 0213 / Industrial Building works
0106 / High, Medium & Low Voltage Net / 0214 / Landscape Design
0107 / E250.1 ERACS / 0215 / Horticultural design
0108 / E250.2 PSSE / 0216 / Heritage/Historical design
0217 / Urban design

Size Of Your Business In Terms Of The Following Structure Per The Sector

Busines size (Please tick):

Sector or Subsector in accordance with the standard Industrial Classification / Size of Class / The total full-time equivalent of paid employees / Total turn-over / Total gross asset value (fixed property excluded)
Manufacturing / Medium / 200 / R51m / R19m
Small / 50 / R13m / R5m
Very small / 20 / R5m / R2m
Micro / 5 / R0.20m / R0.10m
Electricity, gas and water / Medium / 200 / R51m / R19m
Small / 50 / R13m / R5m
Very small / 20 / R5.10m / R1.90m
Micro / 5 / R0.20m / R0.10m
Construction / Medium / 200 / R26m / R5m
Small / 50 / R6m / R1m
Very small / 20 / R3m / R0.50m
Micro / 5 / R0.20m / R0.10m
Retail and Motor Trade and Repair Services / Medium / 200 / R39m / R6m
Small / 50 / R19m / R3m
Very small / 20 / R4m / R0.60m
Micro / 5 / R0.20m / R0.10m
Wholesale Trade, Commercial Agents and Allied Services / Medium / 200 / R64m / R10m
Small / 50 / R32m / R5m
Very small / 20 / R6m / R0.60m
Micro / 5 / R0.20m / R0.10m
Catering, accommodation and other Trade / Medium / 200 / R13m / R3m
Small / 50 / R6m / R1m
Very small / 20 / R5.10m / R1.90m
Micro / 5 / R0.20m / R0.10m
Transport, storage & Communications / Medium / 200 / R26m / R6m
Small / 50 / R13m / R3m
Very small / 20 / R3m / R0.60m
Micro / 5 / R0.20m / R0.10m
Finance & Business Services / Medium / 200 / R26m / R5m
Small / 50 / R13m / R3m
Very small / 20 / R3m / R0.50m
Micro / 5 / R0.20m / R0.10m
Community, social & personal services / Medium / 200 / R13m / R6m
Small / 50 / R6m / R3m
Very small / 20 / R1m / R0.60m
Micro / 5 / R0.20m / R0.10m

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SECTION C

OWNERS/SHAREHOLDERS/MEMBERS/TRUSTEES

Full Names / ID NO / SA Citizen
(Yes/NO) / Capacity
(Member, shareholders etc) / % Ownership / Male/
Female / Handicapped (Yes/No) / HDI Status
Yes/No / Race
(W/C/I/A) / % of time devoted
to business

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DEFINATIONS FOR THE TABLE ABOVE

Definition of ‘HDI’ & “youths” – Historically Disadvantaged Individuals

1. An HDI is defined in terms of Section 1(h) of the Preferential Procurement Policy Framework Act 2000 (Act 56 of 2000) as being a South African Citizen: -

1. Who due to the apartheid policy that had been in place, had no franchise in national elections prior to the introduction of the Constitution of South Africa 1983 (Act no.110 of 1983) or the Constitution of the Republic of South Africa 1983 (Act No. 200 of 1983) (The Interim Constitution) and/or;

1. who is female/male, and/or;

1. who has a disability provided that a person who obtained South Africa citizenship on or after the coming to effect of the Interim Constitution, is not deemed to be an HDI;

1. Generally accepted definition of “Youth” is any persons between the age of 18 and 35 year

SECTION D

Company Tax Details

Company Tax Details

Income Tax Number:

Date Approved:

Expiry Date:

VAT Registration Number:

PAYE Registration Number:

SDL Registration Number:

UIF Registration Number:

SECTION E

Banking Details

Name of Account Holder:

Name of Bank:

Name of Branch:

Branch Number:

Account Number:

Type of Account: Current Account Savings Account

Transmission Account Cheque Account

SECTION F

Professional Affiliations Or Regulatory Body(e.g Saica, CIDB ect.)

Add Details

Afiliation/Regulatory Body

Registration No:

Name:

Indemnity No:

SECTION G

Declaration: Conflict Of Interest

DECLARATION: CONFLICT OF INTEREST
Are any members or shareholders of the business:
a) employed by Dr JS Moroka Local Municipality; or
b) in the service of the state?

YES NO

NOTE: "in the service of the state" means
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 municipality entity;
c) an official of any municipality or municipal entity;
d) any 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.

If (YES) please state the nature if the relationship

Employee Name:

Salary Number:

DECLARATION
I/WE, THE UNDERSIGNED WHO WARRANTS THAT I/WE ARE DULY AUTHORISED TO DO SO
ON BEHALF OF THE ENTERPRISE, CERTIFIES THAT THE INFORMATION SUPPLIED IN TERMS
OF THIS DOCUMENT INCLUDING THE RELEVANT ATTACHMENT IS CORRECT AND ACCURATE
AND ACKNOWLEDGE THAT:
1. The enterprise will be required to furnish documentary proof requested to do so.
2. If the information supplied is found to be incorrect, then Dr JS Moroka Local Municipality may in addition to
any remedies it may have:
a) Disqualify the supplier/contractor for a particular bid/contract/project it may be considered for, or which had been awarded to the supplier/contractor;
b) Recover from the contractor/supplier all costs, losses or damages incurred by Dr JS Moroka Local Municipality as a result of the breach of contract ;
c) De-register the supplier from the accredited suppliers database;
d) Take any other action as may be deemed necessary.

Full Names:

ID Number:

Date:

Duly authorised on behalf of:

Address:

Telephone no:

Signature: Date:

DECLARATION OF BIDDER’S PAST SUPPLY CHAIN MANAGEMENT PRACTICES

1This Standard Bidding Document must form part of all bids invited.

2It serves as a declaration to be used by institutions in ensuring that when goods and services are being procured, all reasonable steps are taken to combat the abuse of the supply chain management system.

3The bid of any bidder may be disregarded if that bidder, or any of its directors have-

1. abused the institution’s supply chain management system;
2. committed fraud or any other improper conduct in relation to such system; or
3. failed to perform on any previous contract.

4In order to give effect to the above, the following questionnaire must be completed and submitted with the bid.

Item / Question / Yes / No
4.1 / Is the bidder or any of its directors listed on the National Treasury’s Database of Restricted Suppliers as companies or persons prohibited from doing business with the public sector?
(Companies or persons who are listed on this Database were informed in writing of this restriction by the Accounting Officer/Authority of the institution that imposed the restriction after the audi alteram partem rule was applied)
The Database of Restricted Suppliers now resides on the National Treasury’s website() and can be accessed by clicking on its link at the bottom of the home page. / Yes / No
4.1.1 / If so, furnish particulars:
4.2 / Is the bidder or any of its directors listed on the Register for Tender Defaulters in terms of section 29 of the Prevention and Combating of Corrupt Activities Act (No 12 of 2004)?
The Register for Tender Defaulters can be accessed on the National Treasury’s website () by clicking on its link at the bottom of the home page. / Yes / No
4.2.1 / If so, furnish particulars:
4.3 / Was the bidder or any of its directors convicted by a court of law (including a court outside of the Republic of South Africa) for fraud or corruption during the past five years? / Yes / No
4.3.1 / If so, furnish particulars:
4.4 / Was any contract between the bidder and any organ of state terminated during the past five years on account of failure to perform on or comply with the contract? / Yes / No
4.4.1 / If so, furnish particulars:

CERTIFICATION

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

CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS TRUE AND CORRECT.

I ACCEPT THAT, IN ADDITION TO CANCELLATION OF A CONTRACT, ACTION MAY BE TAKEN AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE.

………………………………………...…………………………..

Signature Date

……………………………………….……………………………...

PositionName of Bidder

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ANNEXURE “A”

Required document checklist

Please ensure that all documentation listed below is attached (where applicable) to the registration form.

Document NameAttached

Original Tax Clearance Certificate□

Company Registration Certificate □

Most recent municipal accounts for your business location or your personal□

BBBEE Certificate□

Residence i.e. rates, water, refuse, electricity (if applicable) and levy registration

Proof of Registration with professional body□

Confirmation letter banking details certified by bank (page 2)

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