suppliers database registration forms
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Suppliers Database Registration Forms
DELIVER TO:
ENQUIRIES
FOR OFFICE USE ONLY
UMGUNGUNDLOVU ECONOMIC DEVELOPMENT AGENCY RECEPTION
191 BURGER STREET PIETERMARRITZBURG
3200
T: 033 342 3396
E: info@umeda.co.za
W: www.umeda.co.za
2
INTRODUCTION
The Supplier Database Registration Form was specifically designed to provide for. the registration of suppliers on the
uMgungundlovu Economic Development Agency.
Suppliers Database,
In order to ensure that suppliers are considered legitimate, dissipative that the following guidelines are adhered to.
GUIDELINES
Applicants must complete pages 2 to 13, where applicable. 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. Only black ink is to be used when filling in the form.
Applicants are advised that only ORIGINAL Supplier Database Registration Form or PHOTOSTAT copies thereof will
be processed. Any document: that has been retyped or redrafted will be disregarded and returned to the applicant.
It is imperative that only supporting documents with an ORIGINAL signature be submitted.
All signatures to the document must be commissioned by an authorised Commissioner of Oaths. Failure to do so will
result find the applicant not qualifying for registration.
A supplier registered on the Suppliers Database MUST notify uMgungundlovu Economic Development Agency of any
changes to information provided in the initial Supplier Database Registration Form, as captured onto the Suppliers
Database.
Failure to do so may result in such a supplier being removed from the Suppliers Database and/or the cancellation of
contracts awarded to the supplier; based on misrepresentation.
Suppliers providing information incorrectly or fraudulently in their Supplier Database Registration' Form will: be
disqualified from bidding and removed from the Suppliers Database, in addition to action the Province may institute
against such a supplier. Furthermore/in the event of the Province being prejudiced financially; it reserves the right to
take legal action against the supplier.
Any alterations made by the supplier 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.
It remains the responsibility of the supplier to ensure that the information is updated in the Suppliers Database.
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SECTION A: COMPANY INFORMATION
1. Business particulars **
2. Financial information**
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 numbed (Database number)
Name of your business as registered with the registrar
of companies
Trading as
Holding company
Registration number of Company/CC/Trust/Fund number
Business Postal address
Business Physical address
Telephone number
Cellular phone number
E-mail address
Website
Preferred language IsiZulu
Contact person (Full Name & Surname)
Physical Location of Head
Office (if applicable)
Code
C O D E T E L E P H O N E
English Afrikaans
Code
Name of bank account holder
Type of bank account Current
Bank branch number (at least six numbers)
Bank account number
N.B: A certified copy of latest bank statement or original cancelled cheque or original letter from your bank must be
attached.
1 Savings 2 Transmission 3
4
3.Indicate the value of the below stated based on the latest financial statement **
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 expiry date
N.B: A certified copy of a tax clearance certificate must be supplied
Total fixed assets at book value (e.g. land, buildings, plants, equipment)
Vehicles at book value
Number of vehicles
Average stock on hand
Cost of goods produced annually
Quantity produced annually
Units of measure (e.g. tons, kilolitres)
Total current assets (e.g. stock, debtors, cash)
Total current liabilities (e.g. creditors, bank overdraft)
R
R
R
R
R
4. Municipalities **
Please clearly indicate, with an ‘X’, the District Municipality/s where your business operates.
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D D M M
4
D D M M Y Y Y Y
D D M M Y Y Y Y
eThekwini Municipality (DC 20)
uGu Municipality (DC 21)
uMgungundlovu (DC 22)
uThukela Municipality (DC 23)
uMzinyathi Municipality (DC 24)
Sisonke Municipality (DC 47)
Amajuba Municipality (DC25)
Zululand Municipality (DC 26)
uMkhanyakude Municipality (DC 27)
uThungulu Municipality (DC 28)
iLembe Municipality (DC 29)
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5. Previous business information (if applicable)
6. Previous experience (if applicable)
Did your business exist under a different name previously?
If “yes” what was the previous business name?
What was the previous database registration number (database number)?
Yes OR No
List the last three (3) contracts awarded to you (the supplier) or other previous experience related to your core business
CONTRACT 1
Employer/
Department
Contact person
Initials
Telephone number
Was the project completed successfully? (Mark applicable block with an “X”)
What year was the project initiated?
What was the contract value?
Surname
C O D E - T E L E P H O N E
OR No Yes
Y Y Y Y
R
CONTRACT 2
Employer/
Department
Contact person
Initials
Telephone number
Was the project completed successfully? (Mark applicable block with an “X”)
What year was the project initiated?
What was the contract value?
CONTRACT 3
Employer/
Department
Contact person
Initials
Telephone number
Was the project completed successfully? (Mark applicable block with an “X”)
What year was the project initiated?
What was the contract value?
Surname
C O D E - T E L E P H O N E
Yes
OR No
Y Y Y Y
R
Surname
C O D E - T E L E P H O N E
Yes OR No
Y Y Y Y
R
6
SECTION B: CLASSIFICATION OF BUSINESS
1. Type of business **
2. Products & Services**
Please mark with an 'T X" the block applicable to your business or firm AND attach the relevant certified copy
A. Public Company LTD
B. Private Company (PTY) LTD
C. Close Corporation CC
D. Incorporated
E. Sole Proprietor
F. Partnership
G. Trust
H. Co-Operative
I. Welfare organisation
Certified copy of certificate incorporation (CM 1)
Certified copy of certificate of incorporation (CM 1)
Certified copy of CK 1 document and CK 2 applicable
Certified Copy of certificate of incorporation (CM 1 and CM 29)
Certified copy of Identity Document
Certified copy of partnership agreement
Certified copy of trust document
Certified copy of proof of registration with the directorate Co-Operatives
Certified copy of constitution
Total Gross Asset value (fixed property excluded)
Annual turnover
Number of employees
R
R
In order to assist with the classification of. suppliers, please •indicate the industrial sector related to the goods / services that you supply (Only a maximum of FOUR industrial- sectors may be selected), If the supplier selects more than FOUR (4) Industrial Sectors, only the
FIRST FOUR will be considered).
Please mark with an "X" the appropriate block to clearly indicate the industrial sector related to the goods and services that you
supply
Finance and Business service
Banking
Insurance
Investments
Exchanges
Legal service
Securities broker
Credit institutions
Business & management consultant
Chattered accountant
Architects & quantity surveyors
Engineering
Other (Please Specify)
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Community, social & personal services
Collectibles & awards
Fitness equipment
Water sport equipment
Janitorial equipment
Sports equipment & accessories
Cleaning &janitorial equipment
Field & court sports equipment
Gymnastics & Boxing equipment
Camping, outdoor equipment & accessories
Fishing & hunting equipment
Winter sports equipment
Target, table games & equipment
Water, wastewater treatment supply & disposal
Industrial laundry & dry-cleaning equipment
Recreation, playground, swimming, spa equipment & supplies
Other (please specify)
Mining & Quarrying
Fuels
Elements & gases
Gaseous fuels & additives
Fuel for nuclear reactors
Other (Please Specify)
Oil, gas drilling & operating equipment
Well drilling & operating equipment
Oil, gas & Exploration equipment
Lubricants, Oils, greases & anti corrosives
Mining, quarrying machinery & equipment
Transport, storage and communication
Non-motorized cycles
Aircraft
Software
Marine transport
Railway, trainway machinery & equipment
Data voice, multimedia network equipment & accessories
Components for information technology, telecommunications
Aerospace systems, components & equipment
Other (Please specify)
Spacecraft
Transportation service equipment
Computer equipment & Accessories
Hydraulic machinery & equipment
Communications devices & accessories
Transportation components & systems
Structural building products
Automotive speciality tools
8
Catering and accommodation and other trade
Edible Oils & fats
Meat & Poultry products
Sea food
Hotels
Lodges
Vending machines
Museums
Art galleries
Media
Film
Audio, visual presentation & composing equipment
Chocolate sugars, sweeteners, confectionary products
Other (please specify)
Bread & bakery products
Cereal & pulse products
Dairy products & eggs
Camps
Bed & breakfast
Gambling or wagering equipment
Zoological gardens
Photographic filmmaking suppliers
Botanical gardens
Music
Fruits, vegetables, nuts & seeds
Prepared & Preserved foods
Restaurant
Liquor outlets
Institutional food services equipment
Amusement & recreational services
Photographic & recording media
Printing & publishing equipment
Photographic video equipment
Agricultural, forestry and fishing
Live animals
Domestic pet products
Pest control products
Agricultural, forestry, landscape material & equipment
Gymnastics & boxing equipment
Other (please specify)
Animal feed
Animal containment & habitats
Floricultures & silviculture’s
Seeds, bulbs, seedings & cutting.
Saddlery & hams goods
Fertilizers, plant nutrients & herbicides
Fishing & aquaculture equipment
Electricity, gas and water
Power sources
Fluid & gas distribution
Batteries, generator & kinetic power transmission
Atomic, nuclear energy machinery & equipment
Other (please specify)
Electrical wire, cable & hamess
Heating, ventilation & air circulation
Power generation
Industrial filtering & prefinalisation
Industrial pumps & compressors
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Construction
Roads & landscape
Insulation
Plumbing fixtures
Hand tools
Heavy construction machinery & equipment
Pneumatic machinery & equipment
Construction & maintenance support material
Other (Please specify)
Prefabricated structures
Permanent structures
Structural materials & basic shapes
Hydraulic machinery & equipment
Doors, windows & glass
Interior finishing materials
Structural building products
Automotive speciality tools
Wholesale trade, commercial agents and allied services
Durable goods
Other (Please specify)
Non-Durable goods
Retail, motor trade and repair service
Petrol stations
Repair service
Motor vehicles
Other
General merchandise stores
Apparel & accessory stores
Vehicle bodies & trailers
Furniture, furnishing &equipment stores
Fleet management
Manufacturing
Packing supplies
Paper materials
Wound care products
Adhesives & sealants
Lamps & lights
Paper products
Electronic hardware & components
Other (please specify)
Industrial refrigeration
Machined raw stock
Mouldings
Paints, primes & finishers
Dyeing & tanning extracts
Workshop machinery, equipment & suppliers
Machine made parts
Metal waste scrap
Packaging materials
Housing, cabinets & casing
Fabricated bar stock assembles
Light weapons & ammunition
Laboratory supplies & fixtures
10
SECTION C: OWNERSHIP INFORMATION**
Full name/ Name of business
SA Identity number/Business Registration No.
SA Citizen before 27 April 1994 YES / NO
Capacity: Member/ Partners/Proprietor /Shareholder/ Trustee/ Beneficiary
Ownership/ Partnership/Trust/interest %
Gender
F / M
Disability
YES / NO
% of time devoted to the firm
Race (Black; White; Indian; Coloured
; Other)
% %
% %
% %
% %
% %
% %
% %
% %
% %
% %
% %
% %
% %
% %
% %
% %
1. List all persons/entities who are Owners in the business / trust and indicate their involvement in the management / operations of the
business / trust.
Proof of disability provided by a recognised related institution, in the case of handicapped persons, must be supplied. If there is
insufficient space, kindly attach a copy / copies of this page to this ZNT 31, signed by the same person who signs on behalf of the
business/ trust.
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Name of owner
Name of other business
Registration number of business
Position held
Ownership %
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
2. Please indicate any owner who has a controlling ownership interest in another business
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3. Business management **
Identify by name the Historically Disadvantaged Individual (HDI) status and the length of services of the individuals in the
business. Include owners and non-owners responsible for the day-to-day Management and Business decisions.
Cheque signing
Initials
Number of years in service
Surname
Y Y
Race (Mark applicable block with an “X”)
Other (please Specify
White Black Indian Coloured
Signing & co-signing for loans
Initials
Number of years in service
Surname
Y Y
Race (Mark applicable block with an “X”)
Other (Please Specify)
White Black Indian Coloured
Business financing (Overdraft, lease agreement)
Initials
Number of years in service
Surname
Y Y
Race (Mark applicable block with an “X”)
Other (Please Specify)
White Black Indian Coloured
Sureties
Initials
Number of years in service
Approval of major purchase or acquisitions
Initials
Number of years in service
Surname
Y Y
Race (Mark applicable block with an “X”)
Other (Please Specify)
White Black Indian Coloured
Contract signing
Initials
Number of years in service
Surname
Y Y
Race (Mark applicable block with an “X”
Other (Please Specify)
White Black Indian Coloured
Surname
Y Y
Race (Mark applicable block with an “X”
Other (Please Specify)
White Black Indian Coloured
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4. Verification of Information **
I/ We, the undersigned; Miho 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 Supplier Database Registration Form including the annexure/ s with additional
information/ is correct and accurate and acknowledges that:
A. The supplier will be required to furnish documentary-proof, of the information- relating to preferences requested to do so.
B. If the information supplied 'is found to being correct, then the Province addition to any remedies it may have:
i. Disqualify the supplier/contractor for a bid/contact/project it may be considered for, or which had been awarded to the
supplier/contractor.
ii. Recover from the supplier/contractor all costs, flosses or damages incurred or sustained by the Province as a result of
breach. of the contract.
iii. Cancel the contract and claim any damages which the Province 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
Signature
Signed at
Supplier Name
Surname
Date Signed D D M M Y Y Y Y
Signed and affirmed before me at (Commissioner)
Commissioner of oaths signature
Date Signed D D M M Y Y Y Y
Initials
Surname
Business Physical Address
Postal code
Capacity
Area
OFFICIAL STAMP
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SECTION D: DECLARATION OF INTEREST
1. No tender/quotation 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 blood relationship, may
make an offer or offers in terms of an invitation to tender or quotation. In view of possible allegations of
favouritism, should the resulting tender, or part thereof, be awarded to persons connected with or related to
persons in service of the state, it is required that the Vendor or their authorized representative declare
their position in relation to the evaluating/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 and submitted with this
Application:
3.1 Full Name (Vendor or Authorised Representative as mentioned above)
……………………………………………………………………………………………………………………….
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 so, furnish particulars:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
3.7 Have you been in the service of the state for the Yes No
past twelve months?
3.7.1 If so, furnish particulars:
………………………………………………………………………………………………………………
…………………………………………………………………………………………….........................
3.8 Do you have any relationship (family, friend, other) Yes No
with persons in the service of the state and who
may be involved with the evaluation and/or
adjudication of this tender?
3.8.1 If so, furnish particulars:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
3.9 Are you aware of any relationship (family, friend, Yes No
other) between a tenderer and any persons in the
service of the state who may be involved with the
evaluation and/or adjudication of this tender?
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3.9.1 If so, furnish particulars:
…………………………………………………………………………………………………..................
…………………………………………………………………………………………………..................
3.10 Are any of the company’s directors, managers, Yes No principle shareholders or stakeholders in service of the state?
3.10.1 If so, furnish particulars:
…………………………………………………………………………………………………..................
…………………………………………………………………………………………………..................
3.11 Are any spouse, child or parent of the company’s Yes No directors, managers, principle shareholders or stakeholders in service of the state?
3.11.1 If so, furnish particulars:
…………………………………………………………………………………………………..................
…………………………………………………………………………………………………..................
*MSCM 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 an employee of Parliament or a provincial
legislature.
CERTIFICATION
I, the undersigned (name)
………………………………………………………………………………………………………………….
certify that the information furnished on this declaration form is true and correct.
I accept that the state may act against me should this declaration prove to be false. ……………………………………………………………. ……………………………................... SIGNATURE DATE ……………………………………………………………. ……………………………………………… POSITION NAME OF TENDERER
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SECTION E: CHECKLIST
Please use this checklist as confirmation that ALL the required Information/ Documents have been submitted. Please
indicate with an “X”.
Supplier For official use
The following Documents have been attached:
Original Tax Certificate
Certified copy of the Company Registration Certificate
Proof of: Banking Details
The following mandatory fields have been completed:
Business Particulars Municipalities
Financial Information
Type of Business
Products & Services
Ownership Information
Business Management
Verification of Information
Declaration of Interest
FOR OFFICIAL USE
I acknowledge that this form has been checked by me, and all the required Information/Documents have been
furnished.
Signed
Initials
Surname
Date D D M M Y Y Y Y
UMEDA SCM Database Registration: Modified on 18th March 2021.
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