Suppliers Database Registration Form - Department of Economic ...

DEPARTMENT OF ECONOMIC DEVELOPMENT &
TOURISM
Suppliers Database Registration Form
NAME OF SERVICE PROVIDER: _____________________________
SIGNATURE OF SERVICE PROVIDER: _____________________________
PROVINCIAL SUPPLIERS‟ DATABASE REGISTRATION NUMBER: _____________________________
FOR OFFICE USE
Supplier Name
Provincial Supplier’s Database Number
Captured By
Date
Approved By
Date

SECTION A: INTRODUCTION, GUIDELINES & SUBMISSION REQUIREMENTS
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.
2.1. Applicants are advised that only ORIGINAL copies thereof will be processed. Any document that has been retyped or
redrafted will be disregarded and returned to the applicant.
2.2. All signatures to the document must be commissioned by an authorized Commissioner of Oaths. Failure to do so will
result in the applicant not qualifying for registration. Applications with copied signatures will not be considered.
2.3. Suppliers providing information incorrectly or fraudulently in their Forms will be disqualified from bidding and
deactivated/flagged on the database, in addition to any other action the Department may institute against such a
supplier. Furthermore, in the event of the Department being prejudiced financially, it reserves the right to take legal
action against the supplier.
2.4. Any alterations made by the suppliers 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. Only black ink should be used to fill in the form.
2.5 Completion of Questions – please clearly state Yes, No, N/A to questions asked. Do not leave any blank fields.
2.6 Certified Documents – please ensure that a Commissioner of Oaths has certified your Documents
2.7 Documents that need to be attached to your application are:
i. An original valid Tax Clearance Certificate
ii. A certified copy of a valid BEE Certificate
iii. Detailed Company Profile
iv. Detailed CVs of Directors
v. Certified copy of bank statements and a cancelled cheque
vi. Certified Entity Registration documents
vii. Certified copy of identity document of Director/s/Owner
The Suppliers Database Registration Form may be hand delivered, couriered or posted as follows:
• If couriered it must be addressed to the attention of Supply Chain Management. It is the responsibility of the service
provider to ensure that their courier company deposits the bid document into the bid box. Under no circumstances
must documents be given to the Departmental official to deposit into the bid box.
• If hand delivered, Submissions must be deposited into the Bid Box inside the reception area, clearly marked as follows:
The Head: Department of Economic Development and Tourism
Attention: Supply Chain Management
• If posted, it must be addressed to:
The Head, Department of Economic Development and Tourism
Private Bag X9053
PIETERMARITZBURG
3200
CLOSING DATE FOR ALL APPLICATIONS IS 31 OCTOBER 2012.
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SECTION B: COMPANY INFORMATION
1. BUSINESS PARTICULARS
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 number (ZNT number)
Name of business as registered with the Registrar of Companies
Trading as
Holding company
Registration number of Company/CC/Trust/Fund number
Business Postal address
Postal code
Business Physical address
Postal code
Telephone number
Fascimile number
Cellular phone number
E-mail address
Website address
All copies must be certified and may not be older than 3 months
2. CORRESPONDENCE
Contact Person
Initials
First Name
Surname
Please use the below provided guide to indicate your primary, secondary and tertiary method of correspondence, by
indicting the number 1, 2 and 3 in the respective blocks.
1 – Primary
2 – Secondary
3 – Tertiary
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Preferred Correspondence
Post SMS E-mail
Preferred Language
Isizulu English Afrikaans
3. HEAD OFFICE PHYSICAL ADDRESS (if applicable)
Address
City
District Municipality
Province
Postal Code
4. FINANCIAL INFORMATION
Name of bank account holder
Type of bank account
Bank branch number (at least six numbers)
Bank account number
Current Savings Transmission
N.B: A certified copy of latest bank statement or original cancelled cheque or original letter from your bank must be
attached.
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 certificate expiry date
N.B: An original tax clearance certificate must be supplied
PLEASE NOTE: in the case of a joint venture original tax clearance certificates from all parties are to be included.
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5. MUNICIPALITIES
Please clearly indicate, with an „X‟, the District Municipality /s where your business operates
eThekwini Municipality
Ugu Municipality
Umgungundlovu Municipality
Uthukela Municipality
Umzinyathi Municipality
Sisonke Municipality
Amajuba Municipality
Zululand Municipality
Umkhanyakude Municipality
Uthungulu Municipality
Ilembe Municipality
6. AREA OF EXPERTISE
Please indicate which field of expertise you wish to be registered for (one or more fields can be selected)
(please tick if applicable)
Field of Expertise Please tick if applicable
Development Economics
Econometrics
Market Analysis
Industrial Development
Local Economic Development
Spatial Planning
GIS
Transport & Logistics
Infrastructure
Resource Economists
Green Economy
Enterprise Development
Town Planning
Development Financing
Investment Analysis
Other
(Please specify if your field of expertise is not included above)
5

Please Note the following 2 requirements that need to be attached:
1. Detailed Company Profile including experience as per the table format below;
Experience of Company
Project Description Value of Project Contract Period
** Projects that have been undertaken in the last 2 years**
2. Detailed Curriculum Vitaes of all Directors/Owners including qualifications as per table format below.
Qualifications
Name of Director/Owner Qualifications General Experience Specific Experience to the
related field selected in 5
above
6

SECTION C: CLASSIFICATION OF BUSINESS
1. Type of business
Please mark with an “X” the block applicable to your business or firm AND attach the relevant certified copy
A. Company LTD Certified copy of certificate of incorporation (CM1)
B. Private Company (PTY) LTD
Certified copy of certificate of incorporation (CM1)
C. Close Corporation CC Certified copy of CK 1 document and CK2 if applicable
D. Incorporated
E. Sole Proprietor
F. Partnership
Certified copy of certificate of incorporation (CM 1 and CM 29)
Certified document of Identity Document
Certified copy of partnership agreement
G. Trust Certified copy of trust document
H. Co-Operative Certified copy of proof of registration with the directorate Cooperatives
I. Welfare organisation Certified copy of constitution
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SECTION D: OWNERSHIP INFORMATION
FULL NAMES AND SURNAME ID NUMBER % OF OWNERSHIP
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SECTION E: VERIFICATION OF INFORMATION
I/We, the undersigned, who 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 including the annexure /s with additional information, is correct
and accurate and acknowledge that:
A. If the information supplied is found to be incorrect then the Department may, in addition to any remedies it may have:
i. Disqualify the supplier /contractor for a particular bid/contract/project it may be considered for, or which had been
awarded to the supplier / contractor;
ii. Recover from the supplier / contractor all costs , losses or damages incurred or sustained by the Department as a result
of breach of the contract;
iii. Cancel the contract and claim any damages which the Department 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
Surname
Signature
Date signed
Signed at
Supplier name
Signed and affirmed before me at: (Commissioner of Oaths)
Commissioner of Oaths signature
Date signed
Initials
Surname
Business Physical address
Postal code
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Capacity
Area
OFFICIAL STAMP
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SECTION F: CHECKLIST
Please use this checklist as confirmation that ALL the required information/document has been submitted. Please
indicate with an “X”
The following Documents have been attached: Supplier For office use
Original Tax Certificate/s
Certified copy of the Entity Registration Documents (as per page 7)
Certified copy of bank statements & cancelled cheque
Company Profile
Certified copy of ID/s
Curriculum Vitaes of all Directors/Owners
Certified Copy of BEE Certificate
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