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J/common – Nelson Mandela Bay Municipality Supplier Amendment Form – 03 July 2013

Enquiries: Tel 041-5063274 / 041-5063266 email: [email protected]

NELSON MANDELA BAY METROPOLITAN MUNICIPALITY SUPPLI ER DATABASE

(NMBMMSD) AMENDMENT APPLICATION FORM

It is imperative that prospective providers read th e application form carefully and complete it in full.

Database application forms may be obtained from:

Nelson Mandela Bay Municipality

Supply Chain Management Compliance Office

Corner Harrower Road & Buxton Street

Kensington


Budget and Treasury Customer Care Office,

Town Hall

Market Street

Uitenhage

www.mandelametro.gov.za

Tel: 041-5063274

Tel: 041-5063266

Fax:086-5144305

[email protected]

NAFCOC Mandela Bay

22 Chamber House, Grahamstown Rd,

www.nafcoc.gov.za

Nelson Mandela Bay Business Chamber

200 Norvic Drive, Greenacres,

Port Elizabeth

www.nmbbusinesschamber.co.za

Comsec

Old Sydenham Grahamstown Rd,

Port Elizabeth

Completed forms may be delivered: (Only valid origi nal Tax Clearance Certificate is acceptable)

By Hand Post

Database Administrator

SCM Compliance

Cnr Buxton street & Harrower Road


Supply Chain Management: Compliance

PO Box 3188

North End

Port Elizabeth

6001

Queries may be directed to the above listed contact details.

NB: Attach a certified ID copy of the page 9 signatory

AND Messenger’s ID is required on submission of the for m



In addition to a fully completed form, the following documents must be provided where applicable

Nelson Mandela Bay Supplier Database

D O C U M E N T S R E Q U I R E D

Sole Proprietor

Co-operatives Close Corporations and Private Companies

Partnerships Public Company

Business Trust

Non Profit Organisations

(NPO)

Where to get documents

Address Telephone

Company Registration document

Letter of Authority

The DTI Campus Block F (Entfutfukweni)

012 3108789

77 Meintjies Street DTI Call Centre

Sunnyside, Pretoria 0861843384

The DTI Campus Block F (Entfutfukweni)77 Meintjies Street Customer Sunnyside, Pretoria 0861843384

Identity Document for Certificate of Correctness Signatory (Original Certified Copy)

Page 7 Signatory

Page 7 Signatory

Page 7 Signatory

Page 7 Signatory

Page 7 Signatory

Page 7 Signatory

Page 7 Signatory

Proof of Banking Bank statementand cancelled cheque AND Bank Stamp and signature on (Pg 5).

Bank statementand cancelled cheque AND Bank Stamp and signature on (Pg 5).






Branch of bank where account is held

An Original valid Tax Clearance Certificate

For the owner or the business

For the co-operative

For the company / cc

For each individual shareholder

For the company

For the trust For the NPO Receiver of Revenue (SARS)

SANLAM BUILBING CHAPEL STPort Elizabeth

041 –505 7500

BBBEE Rating Certificate ORIGINALLY CERTIFIED COPY

BBBEE Rating Certifcate or EME Certificate if annual turnover is <R5m.

BBBEE Rating Certifcate or EME Certificate if annual turnover is <R5m for the Co-Operative

BBBEE Rating Certifcate or EME Certificate if annual turnover is <R5m for the company / CC

BBBEE Rating Certifcate or EME Certificate if annual turnover is <R5m for the Partnership

BBBEE Rating Certifcate or EME Certificate if annual turnover is <R5m for the company

BBBEE Rating Certifcate or EME Certificate if annual turnover is <R5m for the Trust

BBBEE Rating Certifcate or EME Certificate if annual turnover is <R5m for the NPO

SANAS Approved Rating Agencies

P.A.Y.E Applicable if remuneration is above the threshold & not indicated on Tax Clearance

Applicable if remuneration is above the threshold & not indicated on Tax Clearance

Applicable if remuneration is above the threshold & not indicated on Tax Clearance Certificate





Receiver of Revenue (SARS)


041 –505 7500

If not indicated on Tax Clearance Certificate








041 –505 7500

Laboria House16 Grace StreetPort Elizabeth

Workman’s Compensation YES, if staff remuneration

YES, if staff remuneration


YES, if s taff remuneration




Department of Labour

Laboria House16 Grace StreetPort Elizabeth

041- 506 5000

Security Officer’s Board If applicable – for security industry

If applicable – for security industry






Proof of Disability If owner is disabled a letter from a docter confirming the disability

If shareholder is disabled a letter from a docter confirming the disability






Yes, in the owner or company

Billing Clearance Certificate Yes, in the companies name

Nelson Mandela Metropolitan Municipality

Purchasing Office, Harrower Rd, Port Elizabeth

041 – 5063136

Yes, in the companies name




Do you have staff working for more than 24 hours per week, if YES, please provide proof if not indicated on the Tax Clearance Certificate


041- 506 5000



Department of Labour (sole proprietors)

Trustees details : Letter of Authority

Certificate of Incorporation Section 21

Registrar of Close Corporations & Companies


VAT Registration Yes, if applicable. Based on turnover exceeding R1 000 000 per annum. Contact SARS for further information Receiver of Revenue (SARS)

U.I.F Certificate Do you have staff working for more than 24 hours per week, if YES, please provide proof if not indicated on the Tax Clearance Certificate


Proof of Ownership CERTIFIED COPIES

N/A Shareholding CK1 / CK2

Partnership agreement


Share Certificates


DOCUMENTS REQUIRED FOR VARIOUS BUSINESS TYPES

B U S I N E S S T Y P E (Port Elizabeth Details)

Company Registration CERTIFIED COPIES

N/A Certificate of Incorporation CK1 / CK2


Certificate of Incorporation CM3

Certificate of Incorporation Section 21

Registrar of Co-operatives



NELSON MANDELA BAY METROPOLITAN MUNICIPALITY SUPPLI ER DATABASE

(NMBMMSD) APPLICATION FORM FOR OFFICIAL PURPOSES ONLY

Name of Business

Trading Name

Please tick in box: Y N N/A

Company Registration Document (Certified)

Proof of Ownership / Shareholder certificate (Certi fied)

Originally Certified BBBEE Rating Certificate

Identity Document for Certificate of Correctness Signatory (Certified)

Co-Operatives – Registration Certificate

Proof of Banking Document

UIF Document This MUST reflect on the Tax Clearance Certificate if applicable

Compensation Fund: Letter of Good Standing

VAT Registration Document This MUST reflect on the Tax Clearance Certificate if applicable

PAYE Document This MUST reflect on the Tax Clearance Certificate if applicable

Billing Clearance Certificate

An Original Valid Tax Clearance Certificate (TCC)

Security Officer’s Board Certificate

Contractors Registration Certificate (Issued by the CIDB)

Disability Documents

Please Note: Proof of documents for the entire above is required to ensure successful registration on the Supplier Database. In the event of a document not being required please tick the N or N/A box. Please refer to Page 2 for detailed information with regard to documents required.

SECTIONS TO BE COMPLETED FOR AMENDMENT OF TAX CLEARANCE AND ANY OTHER DETAILS EXCEPT FOR BANK DETAILS

BUSINESS PARTICULARS SECTION 3 BRANCHES AND ACCOUNTS DEPARTMENT DETAILS

SECTION 4

SMME SECTION 6

OWNERS AND SHAREHOLDERS SECTION 7

CERTIFICATE OF CORRECTNESS SECTION 9 DECLARATION SECTION 12

UNDERTAKING SECTION 13

SECTION BELOW IS MANDATORY WHEN AMENDING FINANCIAL DATA AND BANK DETAILS

FINANCIAL DETAILS SECTION 5

SECTION 1



2. BUSINESS PARTICULARS 2.1 Name of Business

2.1.1 Business Trading Name

2.1.2 Head Office

City Code

Postal address

Province

2.1.3 Head Office

City Code

Physical address

Province

2.1.4 Head Office Telephone No.

2.1.5 Head Office Fax No.

2.1.6 E-mail Address

2.1.7 Contact Person for correspondence as per 2.1 1 Title First Name

Surname

2.1.8 Cell No.

2.1.9 Correspondence Method – (Email address – mand atory requirement) Email Address

Fax Number

SECTION 3



3. BRANCHES, SALES AND ACCOUNTS DEPARTMENTS

3.1 Sales Department

Contact Name

Cell No

Email Address

Telephone Fax

3.2 Accounts Department

Contact Name

Cell No

Email Address

Telephone Fax

3.3 Branches

Y N

Do you have any other branches in this region?

If yes, kindly complete 3.3 below

Multiple copies of this page may be submitted if required. Name / Area

City Code

Physical Address

Province

Telephone Fax

Name / Area

City Code

Physical Address

Province

Telephone Fax

Name / Area

City Code

Physical Address

Province

Telephone Fax

Name / Area

City Code

Physical Address

Province

Telephone Fax

SECTION 4



4.1 CORE BUSINESS OPERATION ( M A N D A T O R Y F I E L D ) * *

(Mark with X in applicable fields)

Prime Contractor Sub-Contractor (less than 25 % generated turnover as prime contractor)

Labour-only Contractor

Supplier Manufacturer Legal Service Provider*

Professional Services BUILT Environment*

Education, Training and Development Service Provider (ETD)*

Other**

*NB – All Professional Service Providers in the Built Environment, all ETD Service Providers and all Legal Entities, must contact our offices to request the mandatory additional registration pages applicable to this specific core business sector.

**Other, please specify_____________________________________________________________________________________

4.2 ANNUAL AVERAGE TURNOVER

Indicate annual average turnover excluding Value Added Tax during the past three years:

4.3 ANNUAL AVERAGE TURNOVER*

Indicate annual average turnover excluding Value Added Tax during the past three years:

1_____ R 2_____ R 3_____ R

5. FINANCIAL DETAILS (BANKING)

Banking institution name

Branch Name

Town / City

Branch Code

Banking account number

Account holders name

Account Type

NB. MANDATORY REQUIREMENT The template below must be completed, signed and st amped by a Bank official to validate the bank detai ls.

DATE STAMP OF BANK FOR COMPLETION BY BANK OFFICIAL

Bank Official’s Detail Name Staff Number

Signature Branch Tel Nr

Supplier’s Detail Account nr Branch Code

SECTION 5

6 . BUSINESS INFORMATION ( M A N D A T O R Y F I E L D ) * *

The following table must be completed in order to e stablish whether a business can be classified as an SMME in terms of the National Small Business Amend ment Bill pertaining to the National Small Business Act 102 of 1996. Indicate the sector by ticking the appropriate block in colu mn 1 and then tick the corresponding information bl ocks in columns 2, 3 and 4. If unsure of the applicable sector, please contact the Supplier Database Helpdesk on 0861 225 662.

COLUMN 1 COLUMN 2 COLUMN 3 COLUMN 4

Sector or sub-sectors in accordance with the Standard Industrial Council

Total full time equivalent of paid employees

TICK WHERE APPLICABLE

Total annual turnover

TICK WHERE APPLICABLE Total gross asset value (fixed property

excluded). TICK WHERE APPLICABLE

MORE THAN 100 Medium MORE THAN R 5m MORE THAN R 5m Agriculture

LESS THAN 100 LESS THAN R 5m LESS THAN R 5m

MORE THAN 200 MORE THAN R 39m MORE THAN R 23m Mining and Quarrying


MORE THAN 200 MORE THAN R 51m MORE THAN R 19m Manufacturing


MORE THAN 200 MORE THAN R 51m MORE THAN R 19m Electricity, Gas and Water


MORE THAN 200 MORE THAN R 26m MORE THAN R 5m Construction


MORE THAN 100 MORE THAN R 39m MORE THAN R 6m Retail, Motor Trade and Repair Services


MORE THAN 100 MORE THAN R 64m MORE THAN R 10m Wholesale Trade, Commercial Agents & Allied Services LESS THAN 100 LESS THAN R 64m LESS THAN R 10m

MORE THAN 100 MORE THAN R 13m MORE THAN R 3m Catering, accommodation & other Trade


MORE THAN 100 MORE THAN R 26m MORE THAN R 6m Transport, Storage and Communications


MORE THAN 100 MORE THAN R 26m MORE THAN R 5m Finance and Business Services


MORE THAN 100 MORE THAN R 13m MORE THAN R 6m Community, Social & Personal Services


SECTION 6

7.1 OWNERS AND SHAREHOLDERS

7.1 Attach a list all persons who are shareholders /owners and managers in the business

NB Proof of disability provided by a recognised ins titution in the case of handicapped persons must be supplied.

NB: Declaration form must be completed in full (Sec tion 13).

NB: CERTIFIED COPY OF SHAREHOLDER CERTIFICATES OR P ROOF OF OWNERSHIP/PARTNERSHIP MUST BE SUPPLIED (Multiple copies of this page may be submitted if required.)

7.2 PARTICULARS OF EMPLOYEES

State the total number of permanent and temporary staff employed.

MALE FEMALE

Permanent Temporary Permanent Temporary

BLACK

COLOURED

INDIAN

WHITE

OTHER

DISABLED

7.3 BBBEE STATUS

CERTIFIED COPY of BBBEE Rating Certificate. Please select the relevant status below and attach the relevant document:

Valid BEE Certificate Status Level Of Contribution

EME Certificate

Status Level Of Contribution

Letter / proof from agency that application has been submitted to BEE verification agency (no preference points allocated)

Letter from agency that the supplier is in process of BEE verification (no preference points allocated)

FOR OFFICIAL PURPOSES ONLY BEE Certificate EME LETTER Accounting officer/Auditors details Accounting Officers practice number Physical location of the entity Registration number of the entity Date of issue Expiry Date Status Level of contribution Total black shareholding Total black female www.sanas.co.za/af-directory/bbbee list.php.

SECTION 7

9. CERTIFICATE OF CORRECTNESS OF INFORMATION SUPPLI ED IN THIS DOCUMENT

I/WE, THE UNDERSIGNED, WHO WARRANTS THAT HE/SHE IS DULY AUTHOR ISED TO DO SO ON BEHALF OF THE SUPPLIER, CERTIFIES THAT THE INFORMATION SUPPLIED IN TERMS OF THI S DOCUMENT, INCLUDING THE SUPPORTING DOCUMENTATION, IS CORRECT AND ACCURATE AND ACKN OWLEDGES THAT: -

1. The supplier will be required to furnish documentary proof of the claims if requested to do so.

2. If the information supplied is found to be incorrect then the client may, in addition to any remedies it may have: -

i. Recover from the contractor all costs, losses or damages incurred or sustained by the client as a result of the award of the contract, and/or

ii. Cancel the contract and claim any damages which the client may suffer by having to make less favourable arrangements after such cancellations: and/or

iii. Impose a penalty on the contractor as provided for in the relevant organisation’s regulations.

SIGNED ON THIS _________ DAY OF_________________ 201___ AT_________________________________ __________________________________ ____________________________ (AUTHORISED SIGNATURE) IN HIS /HER CAPACITY A S __________________________________ (PLEASE PRINT NAME OF AUTHORISED SIGNATURE) ON BEHALF OF THE (SUPPLIER’S NAME)_________________________ _____________________________

NB - PLEASE PROVIDE A CERTIFIED COPY OF THE IDENTIT Y DOCUMENT FOR THE SIGNATORY.

NB - Your Tax Clearance Certificate is only valid fo r a twelve (12) month period from the date of issue . A valid Tax

clearance is required to update your tax status. Ple ase note that: Section 43 of SCM regulations prohibit s the award of

tenders to persons whose tax matters are not in ord er.

BBBEE certificate or EME letter is valid for twelve mon ths, it is therefore imperative for service provide rs to regularly

update their BEE status in order to be eligible for B EE preferential points.

SECTION 9

Declaration in terms of Regulations 44 and 45 of the

MFMA Supply Chain Management Regulations by

__________________________________ (the ‘Supplier’)

vis a vis the

Nelson Mandela Bay Metropolitan Municipality

(‘NMMM’) 1. 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 blood relationship, may register as a prospective supplier.

3. In order to give effect to the above, the following questionnaire must be completed by company’s directors, managers, principal shareholders or stakeholders or duly authorised person

3.1 Full Name: …………………………………………………………………………

3.2 Identity Number: ….…………………………………………………………………

3.3 Company Name:….…………………………………………………………………

3.3.1 Company Registration Number:……………………………………………………

3.4 Are you presently in the service of the state∗∗∗∗ YES / NO

3.4.1 If so, furnish particulars.

Name of employer: …………………………………………………….

Saff / Man / Persal number: ……………………………...

Employer’s address: ……………………………………………………... ……………………………………………………..

Designation: …………………………….. ……………………………..

3.5 Have you been in the service of the state for the past YES / NO

twelve months?

3.5.1 If so, furnish particulars.

Name of previous employer: …………………………………………………….


Address: ……………………………………………………... ……………………………………………………..

Position held: …………………………….. ……………………………..

3.6 Are any of the company’s directors, managers, p rincipal YES / NO shareholders or stakeholders in service of the st ate?

3.6.1 If so furnish particulars Name of employer: …………………………………………………….



Designation: …………………………….. ……………………………..

SECTION 12

3.7 Are any spouse, child or parent of the company’s directors, YES / NO

managers, principal shareholders or stakeholders in service of the state?

3.7.1 If so, furnish particulars. Name of employer: …………………………………………………….



Designation: …………………………….. ……………………………..

CERTIFICATION

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

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

I ACCEPT THAT THE STATE MAY ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO

BE FALSE. ……………………………………… ……………………………………..

ID Number Position …………………………………. ………………………………………

Signature Date ∗∗∗∗ 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 (f) an employee of Parliament or a provincial legislature.

Undertaking by

__________________________________ (the ‘Supplier’)

vis a vis the

Nelson Mandela Metropolitan Municipality

(‘NMMM’)

Whereas:

(a) the Supplier delivers goods or renders services to NMMM;

(b) NMMM is liable to pay the Supplier for goods delivered or services rendered; and

(c) the Supplier is liable pay NMMM for any due municipal rates and taxes or municipal service charges and any other indebtedness owed by the Supplier to the NMMM

Now therefore the Supplier undertakes the following:

1. In the event of the Supplier being in arrears in respect of any municipal rates and taxes or municipal service charges and any other indebtedness owed by the Supplier to the NMMM; which is / are due:

1.1 the Supplier shall make satisfactory and reasonable written settlement arrangements with the NMMM for the payment thereof; and

1.2 failing which, the NMMM may set-off any such due Municipal rates and taxes or Municipal service charges and any other indebtedness owed by the Supplier to the NMMM, from any amount owed by the NMMM to the Supplier;

2. To co-operate with the NMMM and to do all things and sign all such documents (and/or procure same to be done) as may be necessary or requisite in order to give proper and due effect to the terms of this undertaking or any matter arising there from in accordance with its intent and purpose;

3. No extension of time or indulgence granted by the NMMM shall be deemed in any way to affect, prejudice or derogate from its rights in any respect in terms of this undertaking, nor shall it in any way be regarded as a waiver of any of the NMMM’s rights hereunder; and

4. The Supplier shall not be entitled to cede any of its right’s nor delegate any of its obligations in terms of this undertaking to any other person without the prior written consent of the NMMM.

Thus done and signed by the Supplier at ____________ _________________________on _________ 201_ __________________________________

(The Supplier) duly authorised

SECTION 13