SUPPLIER DATABASE REGISTRATION FORM – 2016
Section 1: Company Details and General Information
Name of Company: Trading Name(if applicable):
Street Address: Postal Address:
City: Code:
Email Address of Contact Person:
1.
2.
Telephone Number:
WWW Address: Cellphone Number:
Contact Name and Title: Alternative Contact Person:
Parent Company (Full Legal Name):
Subsidiaries, Associates & Overseas Representative(s) - (attach a List if necessary)
Type of Business (Mark one only):
Corporate/Limited: Sole Trader: Trust: Other (specify):
Nature of Business:
Manufacturer: Authorised
Agent:
Trader: Consultant: Other (specify)
Year Established: Company Registration No. (please attach company
reg. documents):
Income Tax Number (please attach valid Tax
Clearance Certificate):
VAT No:
B-BBEE Status Level (please attach valid B-BBEE
Certificate):
EXEMPT ENTERPRISE (YES/NO)(please attach
certified affidavit/certificate):
Core Commodity:
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Section 2: Financial Information
Annual Turnover for the past 3 years (please provide most recent annual/audited financial report):
Year:
ZAR:
Year:
ZAR:
Year:
ZAR:
Bank Details (please provide proof in the form of an original letter from the bank/Cancelled Cheque):
Bank Name: Bank Account No.:
Authorised Contact Person in Accounts:
Name: Designation:
Section 3: Technical Capability and Information on Goods/ Services Offered
Professional/Trade Membership (e.g. PrEng) (please provide copy/ies of latest certification):
Quality Assurance Certification (e.g. ISO 9000 or Equivalent) (please provide copy/ies of latest certification):
Safety, Health & Environment (SHE) (please provide copy of latest policy in place):
For goods only, do those offered for supply conform to SABS/International quality standards? (YES/NO):
List Below your core goods/services offered:
Description National/International Quality Standard to which item conforms
Disclaimer: By completing this form does not automatically mean you will be added to our supplier database. There will be a review and an evaluation process that must take place first.
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TERMS AND CONDITIONS:
1. The Gautrain Management Agency (GMA) reserves the right to accept or reject any application
without being obliged to give any reasons in this respect.
2. Registration onto the (GMA) supplier database does not guarantee business opportunities.
3. The forms must be completed in full and signed off by the duly authorized signatories.
4. Full signatures are required when alterations are made in this document.
5. If the information required is not applicable to your business, clearly insert the symbol “N/A” in the
appropriate space.
6. Mark the appropriate box with a “tick”/”X” where it is applicable to your business.
7. If the space is left blank, the form will be regarded as incomplete and may lead to automatic
disqualification.
8. No faxed or emailed applications will be accepted. Only original and signed copies of application will
be accepted.
9. Suppliers may not alter the application form in any way.
10. A company profile must accompany the registration form but will not be accepted as a substitute for
this application form.
11. Applicants will be contacted via email and must therefore submit alternative email addresses.
12. Suppliers registered onto the Supplier database should ensure that they furnish the GMA with any
change to the status of the information initially provided as and when the information changes.
13. It is the duty of the supplier to ensure the GMA is always in possession of an original valid tax
clearance certificate, B-BBEE certificate and valid bank details.
14. Suppliers must attach original/certified relevant industry accreditation where applicable.
15. Suppliers that have been registered onto the database will be continuously monitored for their
performance on work awarded to them.
16. The continuous monitoring process will form the basis of evaluating supplier’s performance, which
will have impact on future procurement opportunities with the GMA.
17. The completed form and all required supporting documentation must be placed in an enveloped and
hand delivered/ dropped the tender box at the following address:
Physical Address of Tender Box: 44 Grand Central Boulevard, Midrand (Off R101 Old
Johannesburg Road)
Hours of access to Tender Box: Between 07:00 and 17:00 (Weekdays only)
Information to be marked on
envelope containing application:
Gautrain Management Agency
SCM Unit
SUPPLIER DATABASE REGISTRATION - 2016
Name of Supplier:
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18. Please mark the back of the envelope with Sender (Business Name), Contact Person and
Telephone Number.
19. Application forms received after closing date will not be considered.
20. A list (not exhaustive) of categories of goods/services that a supplier wishes to register
for as a supplier is attached as annexure A.
DECLARATION:
I, the undersigned, (NAME IN FULL) ______________________________________________________certify
that the information furnished is true and correct.
SIGNATURE:______________________________________________________________
DATE:_____________________________
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SBD 4
DECLARATION OF INTEREST
1. Any legal person, including persons employed by the state¹, or persons having a kinship with persons
employed by the state, including a blood relationship, may make an offer or offers in terms of this invitation to
bid (includes an advertised competitive bid, a limited bid, a proposal or written price quotation). In view of
possible allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons employed
by the state, or to persons connected with or related to them, it is required that the bidder or his/her
authorised representative declare his/her position in relation to the evaluating/adjudicating authority where-
- the bidder is employed by the state; and/or
- the legal person on whose behalf the bidding document is signed, has a relationship
with persons/a person who are/is involved in the evaluation and or adjudication of the bid(s), or where it is
known that such a relationship exists between the person or persons for or on whose behalf, the declarant acts
and persons who are involved with the evaluation and or adjudication of the bid.
2. In order to give effect to the above, the following questionnaire must be completed and submitted
with the bid.
2.1 Full Name of bidder or his or her representative: ……………………………….……………………………….
2.2 Identity Number:……………………………………………………………………………………………………………………………
2.3 Position occupied in the Company (director, trustee, shareholder, member):……………………….……….
2.4 Registration number of company, enterprise, close corporation, partnership agreement or
trust:…………......................………………………………………………….................................
2.5 Tax Reference Number: …………………………………………………………………………………….
2.6 VAT Registration Number: ………………………………………………………………………………....
2.6.1 The names of all directors / trustees / shareholders / members, their individual identity numbers, tax
reference numbers and, if applicable, employee / PERSAL numbers must be indicated in paragraph 3 below.
2.7 Are you or any person connected with the bidder YES/NO
Are you or any person connected with the bidder presently employed by the state? YES/NO
2.7.1 If so, furnish the following particulars:
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Name of person / director / trustee / shareholder/ member: ……....……………………………………
Name of state institution at which you or the person
connected to the bidder is employed: ……………………………………………………
Position occupied in the state institution: ………………………………………………………………………..
Any other particulars:
………………………………………………………………
………………………………………………………………
………………………………………………………………
2.7.2 If you are presently employed by the state, did you obtain the appropriate authority to undertake
remunerative work outside employment in the public sector? YES/NO
2.7.1.1 If yes, did you attach proof of such authority to the bid document? YES/NO
(Note: Failure to submit proof of such authority, where applicable, may result in the disqualification of the bid.
2.7.1.2 If no, furnish reasons for non-submission of such proof:
…………………………………………………………………….
…………………………………………………………………….
…………………………………………………………………….
2.8 Did you or your spouse, or any of the company’s directors / trustees / shareholders / members
or their spouses conduct business with the state in the previous 12 months YES/NO
2.8.1 If so, furnish particulars:
…………………………………………………………………..
…………………………………………………………………..
…………………………………………………………………...
2.9 Do you, or any person connected with the bidder, have YES/NO
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any relationship (family, friend, other) with a person
employed by the state and who may be involved with
the evaluation and or adjudication of this bid?
2.9.1 If so, furnish particulars.
……………………………………………………………...
…………………………………………………………..….
………………………………………………………………
2.10 Are you, or any person connected with the bidder, aware of any relationship (family, friend, other)
between any other bidder and any person employed by the state who may be involved with the evaluation and
or adjudication of this bid? YES/NO
2.10.1 If so, furnish particulars.
………………………………………………………………
………………………………………………………………
………………………………………………………………
2.11 Do you or any of the directors / trustees / shareholders / members YES/NO
of the company have any interest in any other related companies
whether or not they are bidding for this contract?
2.11.1 If so, furnish particulars:
…………………………………………………………………………….
…………………………………………………………………………….
…………………………………………………………………………….
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3 Full details of director /trustees/members/shareholders.
Full Name Identity Number Personal Income Tax
Reference Number
State Employee
Number / Persal
Number
4. DECLARATION
I, THE UNDERSIGNED (NAME)………………………………………………………………………
CERTIFY THAT THE INFORMATION FURNISHED IN PARAGRAPHS 2 AND 3 ABOVE IS CORRECT.
I ACCEPT THAT THE STATE MAY REJECT THE BID OR ACT AGAINST ME SHOULD THIS DECLARATION
PROVE TO BE FALSE.
NAME OF BIDDER
IDENTITY NUMBER
POSITION
SIGNATURE OF AUTHORISED SIGNATORY
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CHECKLIST Documents to be submitted by an applicant for eligibility checking during the registration process. If any of the
required documents are not submitted as prescribed may invalidate the application. The applicant is to indicate
that the documentation is complete and included in the application document by completing the table below.
ITEM DESCRIPTION YES NO
1. Is your supplier database registration form completed in full and
signed?
2. Have you completed SBD 4 (Declaration of Interest) in full and
signed?
3. Have you submitted the following documents:
4. Original valid tax clearance certificate
5. Original valid B-BBEE certificate
6. Original bank details – either a cancelled cheque or letter from the
bank
7. Company profile
8. Most recent annual/audited financial report
9. Valid original/ certified copy of proof of professional/trade
membership
10. Valid original/certified copy of proof of quality assurance
11. Certified copies of Original of Company Registration Documentation
NB: Certification stamp must be original and no more than 3 months
old as at date of closing of tender
1. certificate of registration,
2. change of name certificate (if applicable)
3. register of directors, and most current registered business
address
(Company Registration: CM1 and CK1, Change of Name
Certificate:CM9, Latest Registered address: CM22,Most current
register of directors CM29 and CK2)
12. Original certified copies of shareholders/directors/owners/members
identity documents
13. SHE (Safety , Health and Environment)
Tick to indicate that the information is included
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ANNEXURE A LIST OF COMMODITIES
A commodity is a category of goods/services that business wishes to register for as a supplier. The list is for your
information only. Please do not submit this list with your application form.
Advertising (Placement of Advertisements
Electronic Media
Outdoor Media
Print Media
Archiving & Related Services
Archiving & Related Services
Assets & Goods
Electronic Equipment (projectors, Cameras, etc.)
Kitchen Electrical Appliances (e.g. Microwave, Urn, Electric Kettle, Coffee Machines)
Office Equipment
Office Furniture (Indicate % local content in production of all items of furniture that you supply)
Assets Services
Audio & Video Systems (Maintenance & Support)
Panel Beating / Spray Painting
Refrigeration Equipment Repairs
Repair of Office Furniture
Construction Related
Paving
Other
Corporate Clothing & Gifts
Corporate Clothing, Promotional Items & Gifts(indicate % local content in production of all textile items
that you supply)
Framing of wall posters
Document Services
Courier Services (incl. Postal Services)
Content Development/Editing
Copy Editing
Graphic Design
Transcription
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HR Related Services
Business Management
Change Management Consultants
Coaching Consultants
Consultants
Employment Equity Strategy Development
Executive Search Consultants
HR Management Consultants
HR Strategic Planning & Development
HR Strategic Planning Facilitation
Knowledge Management Solution
Organisational Dynamics Consultants
Organisational Transformation
Performance Management
Personal Development
Recruitment Agencies
Remuneration & Salary Structuring/benchmarking Consultants
Skills Analysis & Development Consultants
Staff Wellness Services
Team Building Organisers
Transcription Services
Workshop Facilitators
IT Related Services
Boardroom Solutions
Cloud Services
General IT Software and Hardware
Infrastructure Specialist for: Network Infrastructure Air-Conditioning Access Control CCTV Server Rooms
IT Hardware & Network Maintenance & Support
IT Network Cabling
IT Professional Services (Consulting)
IT Security Services
IT Software (Operating & Other)
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Laptop & Desktop Hardware and Software
Mobile Applications and Solutions
Printers and Printer Consumables
Security Solution Systems
Server Hardware and Software
Specialist IT Services, Architecture, Security, etc.
Telephony and Collaboration Systems
Office Management Goods
Carpets / Carpeting Installation
Fresh Milk
Design and Making of Uniforms
Dry Groceries (Wholesale and Retail)
Household Cleaning Materials
Shelving (Steel & Wood)
Stationery
Other Groceries
Office Management Services
Catering
Cleaning (General and Specialised, incl. Carpet Cleaning)
Fire Detection, Prevention and Security Systems
First Aid Supplies / Equipment / Kits (OHASA)
Pest Control / Fumigation
General Handy Man
Pot Plant Supply & Servicing
Sanitation
Supply of Newspapers, Journals, etc.
Maintenance & Related Services
Air Conditioning Specialist
Minor Building Contractors
Carpet / Upholstery Cleaning
Construction Maintenance Services
Electrical (Globes, Plugs, Wire, etc.) Maintenance
Furniture Repairs & Maintenance
Furniture Removals
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Plumbing (Toilet Seats, Washers, Taps, etc.)
Recycling Services
Marketing & Communications Services
Corporate Communications
Corporate Promotional Gifts
Digital/Website/Online Services
Geographic Information Systems (Apps & Maps)
Social Media Research
Design & Printing
Photocopying
Aerial Photography
Filming & Videography
Communications and Marketing Research
Data Analysis
Events Management
Communications & Stakeholder Management
Media Monitoring Research
Media Management
Transport for Events
Exhibition Stands
Brand Management
Public Relations & Consulting Services
Stakeholder Perception Survey Services
Printing & Related
Copying Services
Printing, Layout & Design (e.g. Annual Report, Folders, Business Cards, Diaries, brochures, etc.)
Professional Services: Other
Accounting & Auditing Services
Architects
Asset Management Consultants
Business Advisory Consultants
Business Analysis & Design Consultants
Business Management Consultants
Business Process Re-Engineering Consultants
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Business Solutions Consultants
Corporate Compliance Services
Corporate Governance Services
Engineers
Environmental auditing, consulting and specialist reporting services
Financial & System Integration Consultants
Financial Administration Consultants
Financial Planning Consultants
Financial Systems Consultants
Forensic Investigations
Geographic Information Systems
Governance Consultants
Health & Safety Programmes (CPR)
Health, Safety and Environmental legal auditing services
Industrial Theater
Internal Audit and Consulting
Procurement Advisory Services
Project Management Consultants
Public Relations & Consulting Services
Quantity Surveyors
Risk Management Consultants
Security (Physical/digital)
Strategic Planning & Development Consultants
Strategic Planning Facilitation
Travel, Accommodation & Related
Accommodation
Car hire
Transport Services (Buses, Shuttles, Other
Travel Agencies
Venue Finders
Rental
Crockery & Cutlery
Décor
Office Equipment
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Screens
Security
Locks & Keys
Safes
Vehicle Tracking Systems
Training (SETA Accredited etc.)
Business Process Mapping & Modelling Training
Business Writing Skills
Career Management
Change Management Training
Communication Skills
Conflict Management Training
Corporate Secretariat Training
Diversity Training
Document Management Training
Employee Wellness Programmes
Employment Equity Training
Etiquette Training
Facilities Management Training
Financial Management Training
Governance Training
Health, Safety and Environmental training services
Human Resources Development/Management Training
Internal Audit Training
Interpersonal Skill Training
IT Development Training
Labour Law Training
Leadership/ Management Development Programmes
MS Office Training
Negotiation Skills
Occupational Health & Safety Training (First Aid Training etc.)
Organisational Development Training
Performance Management Training
Personal Assistant Training
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Policies & Procedures Development Training
Prevention & Detection of Procurement & Contract Fraud Training
Project Management Training
Report Writing Skills
Skills Development Facilitator Training
Strategic Planning Training
Supervisory Development Training
Time Management Training
Women in Leadership Training
Other Commodities Not Listed
(PLEASE ENSURE THE COMODITIES YOU LIST UNDER THIS SECTION ARE NOT COVERED ABOVE)