SUPPLIER PROFILE - Ugu District Municipality

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 2 of 12SECTION A: Contact details„Trading as‟ name of business: ____________________________________________(Contracts/Orders/Cheques will be issued in this name and invoices must reflect it)Registered name of business:___________________________________________Physical address of business:Building / complex name: ____________________________________________________Street name and number: _____________________________________________________Suburb: ______________________City: _________________________________________Code:_____________ Municipal Area: ______________________________________Postal address of business: (This is the address to which an Invitation to Tender / enquiry andorders / contracts must be sent to)Postnet suite number ________________________________________________________P O Box _______________________________________________________________________________________________City/Town: _______________________ Code: _______Telephone numbers of business: Code: __________Number: ________________________Alternative number of business: Code: __________Number: _________________________Sales person fax number: Code: __________Number: ______________________________Alternative person fax number: Code: __________Number: __________________________(Used by Ugu District Municipality for electronic faxing of Request for Quotations, Contractsand Purchase orders)Is this a dedicated fax number? (y/n) ____________________________________________Business e-mail: ____________________________________________________________Your own business contact person/sales representative name and telephone number:___________________________________Tel: ___________________________________

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 3 of 12SECTION B: Business DetailsBusiness Registration number _________________________________________________(in case of a sole proprietor, please furnish identity number plus copy of identity documents)Income Tax number of business: ______________________________________________VAT Registration number:CIDB registration number:Name of Banking Institution:Name of account________________________________________________________________________________________________________________________________________________________________________________________Banking account number: ____________________________________________________Branch: __________________________________________________________________Branch code: ______________________________________________________________Please indicate (x) the geographical areas where your business is located:GautengKwa-Zulu NatalWestern CapeMpumalangaFree StateEastern CapeNorth WestNorthern CapeNorthern ProvinceAre you locally based, i.e. within Ugu District Municipality yes/no ____________Previous name of business (if applicable)__________________________________________________________________________________________________________________________________

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 4 of 12BUSINESS OWNERSHIPList of directors / owners / partners /members: (Attach your own list if the space provided isinadequate)1. Name: ___________________________________________________________Position: _________________________________________________________% Shareholding/Members Interest _______________________________________Identity Number____________________________________________________Nationality________________________________________________________Gender:__________________________________________________________2. Name:____________________________________________________________Position: _________________________________________________________% Shareholding/Members Interest ________________________________________Identity Number____________________________________________________Nationality________________________________________________________Gender:__________________________________________________________3. Name: ___________________________________________________________Position: _________________________________________________________%Shareholding/Members Interest _____________________________________Identity Number____________________________________________________Nationality________________________________________________________Gender:__________________________________________________________

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 5 of 12DECLARATION OF INTEREST1 No bid 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 bloodrelationship, may make an offer or offers in terms of this invitation to bid. In view ofpossible allegations of favouritism, should the resulting bid, or part thereof, be awardedto persons connected with or related to persons in service of the state, it is required thatthe bidder or their authorised representative declare their position in relation to theevaluating/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 andsubmitted 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 / NO3.6.1 If so, furnish particulars……………………………………………………………….………..………………………………………………………………………………………….3.7 Have you been in the service of the state for the past twelve months? ……….YES / NO3.7.1 If so, furnish particulars……………………………………………………………….…………………………………………………………………………………………………...3.8 Do you, have any relationship (family, friend, other) with persons in the service of thestate who may be involved in the evaluation and / adjudication of this bid? …..YES?NO3.8.1 If so, furnish particulars……………………………………………………………….……………………………………………………………………………………………………3.9 Are you, aware of any relationship (family, friend, other) between a bidder and anypersons in the service of the state who may be involved with the evaluation and oradjudication of this bid? …………………………………………………………….YES / NO3.9.1 If so, furnish particulars……………………………………………………………….……………………………………………………………………………………………………3.10 Are any of the company‟s directors, managers, principal shareholders or stakeholders inservice of the state?..................................…………………………………….YES / NO3.10.1 If so, furnish particulars……………………………………………………………….……………………………………………………………………………………………………3.11 Is any spouse, child or parent of the company‟s directors, managers, principalshareholders or stakeholders in service of the state?.....................................YES / NO3.11.1 If so, furnish particulars…………...…..……………………………………………………………………………………………..……………………………………………………………

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 6 of 12BUSINESS MANAGEMENTList of management: Please indicate level of participation in the business (Attach your own list ifthe space provided is inadequate)1. Name: ___________________________________________________________Position: _________________________________________________________Identity Number: ___________________________________________________Nationality: ________________________________________________________Gender: __________________________________________________________2. Name:____________________________________________________________Position: _________________________________________________________Identity Number____________________________________________________Nationality________________________________________________________Gender: _________________________________________________________3. Name: ___________________________________________________________Position: _________________________________________________________Identity Number_____________________________________________________Nationality_________________________________________________________Gender: __________________________________________________________

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 7 of 12SECTION C: Business Classification1) Please indicate (x) in the business classification area applicable to your business:Professional servicesAuxiliary servicesMaterial supplyConstructionVehicles servicesWorkshop servicesCorporate ServicesOther specifyIf there are operations performed by your business, not reflected in Section C (3) below, pleasecomplete this section [i.e. C (2)].2) Nature of Operations:

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 8 of 12Please indicate (X) nature of business operationsVehicle Services Construction Material supply Auxiliary servicesAdvertising/communicatioPanel beating Concrete works Building materialsnAuto Electrical Pre-cast concrete manuf. Cleaning supplies Carpet cleaningBrakes and Clutch Demolition Safety Clothing Cleaning servicesTransmissions Electrical contracts Office furniture Catering/vendingTyres Evacuation systems Office supplies& stationery Catering equipment hireBatteries Fencing Fire protection equipment Computer hardwareMechanical work General building work Oil & Lubricants Computer softwareWindscreens Glazing Bulk gases Vehicle hireCommunicative Goods transport hire Chemicals TrainingEngine overhauls Earthworks Fuel Arts and cultureMetalwork & burglarTowing Servicesguards Hardware supplies Horticultural servicesUpholstery Sheeting Workshop tools Garden MaintenanceRadiator repairs Industrial Painting Food supplies Site cleaningDecorative painting Plumbing material LandscapingWorkshop Services Paving Pipe& irrigation supplies Interior decoratingElectrical component supplies Plumbing Hydraulics & Pneumatics Waste managementElectrical motor repairs Pumping installation Vehicle Spares Laundry servicesTransformer services Road works Pumps / spares Locksmith servicesPump repairs Special contracts Bolts & nuts Courier servicesMechanical seals &Motor rewindsSand and stonepackingsHealth care servicesHydraulic & Pneumatic repairs Equipment hire Lifting equipment Municipal servicesBearingsPersonnel servicesProfessional services Glass specialists Pest removal servicesInsurance servicesFinancial servicesArchitectsLegal servicesLand surveyorsMedical practitionersProject managersQuantity surveyorsTown plannersEngineersConsulting Engineers (Civil/Structural)Consulting Engineers (Electrical)Consulting Engineers (Mechanical)Consulting Engineers(Multidisciplinary)Consulting Engineers (Geotechnical)Social development consultantsReal estateTravel agenciesSecurity & access controlAir conditioning systemsTelemetryWater PurificationCorporate servicesCorporate Clothing /giftsEvents ManagementPrinting/graphic designSound equipment

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 9 of 12SECTION D: SUPPLIER PROFILEIn order for Ugu District Municipality to establish a profile of its suppliers, please complete thefollowing:Commercial:1. Name 3 commercial references/referees of previous projects and provide their name(s) andtelephone number(s):Financial:1. Are there any pending legal proceedings or previous judgements against your business orhas your business ever been declared bankrupt? (y/n)_____If yes, please elaborate:___________________________________________________________________________________________________________________________________________________________________________________________________________________________Technical:1. 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, indicate productsand to which standards:_________________________________________________________________________________________________________________________________________________Quality:1. Does your business operate a Quality Management System covering theproduct/service applying for? (y/n) _______Please elaborate:__________________________________________________________________________________________________________________________________________________________________________________________________________________________

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 10 of 122. Has your Quality Management System been assessed and certified by any National /Internationally recognised accredited body? (y/n)____If yes, please provide copy ofcertificate.Safety:1. Does your business have an Occupational Health and Safety Policy complying with theOccupational Health and Safety Act (OHSA)? (y/n)______________________________2. Are you registered with Compensation of Occupational Injuries and Diseases Act (COID)?(y/n) ___________ COID registration number: __________________________Environmental:1. Do you have an Environmental Policy in place? (y/n) ____________________________2. Does your facility routinely work with any hazardous substances? (y/n)______________Human Resources:1. Briefly state your Affirmative Action (AA) policy: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Facilities, plant & equipment:1. Please give a summary of your plant and facilities: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 11 of 122. Please give a summary of your equipment: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

UGU DISTRICTMUNICIPALITYSupplier Application FormDate:Page 12 of 12SECTION E: DECLARATIONI/WE, THE UNDERSIGNED, WARRANTS THAT I AM/WE ARE DULY AUTHORISED TO DO SO ON BEHALFOF THE ENTERPRISE TO CERTIFY THAT THE INFORMATION SUPPLIED IN TERMS OF THIS DOCUMENTWITH ADDITIONAL INFORMATION IS CORRECT AND ACCURATE AND ACKNOWLEDGES THAT1. The enterprise complies with all requirements for recognition as a Black / Priority PopulationGroup / Black Business Enterprise / Priority Business Enterprise / Woman Business Enterprise /Disabled Person Enterprise / SMME (Delete as applicable) as defined, and2. The contents of this Affidavit are within my personal knowledge, and save where statedotherwise are to the best of my belief both true and correct.3. The enterprise will be required to furnish documentary proof if requested to do so.4. If the information supplied is found to be incorrect then the Ugu District Municipality in addition toany remedies, it may have; mayiiiRecover from the Enterprise all costs, losses or damages incurred or sustained by theMunicipality as a result of the award of any business, and/orTake any other action as may be deemed necessary.Signature................................................................................................................................................Name…...................................................................................................................................................I.D Number..............................................................................................................................................Duly authorised to sign on behalf of: ……...............................................................................................Address................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Telephone..............................................................................................................................................SECTION F: SWORN AFFIDAVITSigned and sworn to before me at …............................................................................................on this the ..........................day of .............................................by the Deponent, who hasacknowledged that he/she knows and understands the contents of this document, that it is true andcorrect to the best of his/her knowledge and that he/she has no objection to taking the prescribed oath,and that the prescribed oath will be binding on his/her conscience.Commissioner of Oaths....................................................................................................................NOTE: Both the Deponent and the Commissioner of Oaths must initial all pages of thisApplication form.