Supplier Database Application – KwaZulu Natal CET College

CETC Suppliers Database Application Form

CSD Number

Type Of Entity *

Full Registered Name Of Business *

Details Of Owners And Directores

Name *

Capacity *

Citizenship *

ID Number *

Gender *

Race

Supplier Information

Registration Number Of Company/Close corporation

Upload Copy Of Registration Certificate

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Description Of The Core Business Supplier

Description of specific expertise vested in the company

Is permission granted by the applicant that the financial position of the supplier and the ability to manufacture or to supply goods or to render a service may be examined before its offer is considered for acceptance?

Income Tax Registration Number

VAT Registration number if registered, or indicate if not registered

Employees Tax Registration Number If Registered for Employees Tax

Please A Valid Tax Clearance Certificate

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Upload an Authorization form for College to obtain a Tax Clearance from SARS if an original copy is not attached

Tax Clearance Verification Pin

Date

UIF Number If Registered For UIF

Workmen’s Compensation Fund Registration Number If Registered For Workmen’s Compensation Fund

Please Upload A Certificate Of Good Standing From The Compensation Commissioner

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Web Address

Telephone Number

Fax Number

Email Address

Physical Address

Postal Address

Contact Person

Please State Your NHBRC Status

Please Upload A Valid Certificate If Applicable

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Please State Your CIDB Status

Please Upload A Valid Certificate If Applicable

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Please Indicate Any Professional / Regulatory Bodies With Which You Are Accredited

Registration Number

Please Upload The Proof Of Registration / Accreditation As May Be Relevant

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Please Indicate Whether You Are Registered In The Central Supplier Database

Please Upload Your Proof Of Registration If Applicable

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Please State ISO Status

Please Upload The Relevant Proof As May Be Applicable

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Please Provide The Names And Contact Details Of 3 Trade References For The Goods And / Or Services For Which You Wish To Register On The Supplier Database?

Please Upload A Copy Of Your Latest Annual Financial Statement (Audited If Applicable) To Your Application?

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Please State Your Annual Turnover As Per Your Latest Annual Financial Statements?

ZAR

Please State The Number Of Full Time Employees

Please State The Number Of Part Time Employees

Please State The Number Of Other Employes (Please Specify)

Please Specify The District And The Number Of Residents Of That District That Youy Have In Your Employment

How Many Disabled Persons Are In your Employment

How Many Women Are In Your Employment

Please Provide Proof Of Your Address, In The Form Of A Municipal Account, Or Suitable Alternative Evidence Of Your Address

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Contact Details For Sales And Accounts Departments

Sales Contact Person Name

Sales Contact Person Tel No

Sales Contact Person Fax No

Sales Person Email

Accounts Contact Person Name

Accounts Contact Perosn Tel No

Accounts Contact Person Fax No

Accounts Contact Person Email

Please Complete The List Of The Main Commodities And/Or Services In Respect Of Which You Wish To Be Registered As An Accredited Prospective Service Provider And Provide Information On Those That Are Not Listed

Black Economic Empowerment Act Information (Kindly Supply The Following Information, If Applicable As Set Out Below And Supply Documentary Proof As Requested)Details Of Previously Disadvantaged Equity Holders

Name

ID Number

Equity Holding %

Share Holding Certificate

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Please State Your BBBEE Rating

Please Upload A Valid Supporting Affidavit Or BBBEE Certificate

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Human Resource Development:

Number Of Employees

Number Of Previously Disadvantaged Individuals Employed

Details Of Previously Disadvantaged Individuals In Management Position:

Name

ID Number

Position Occupied

Details Of BBBEE Businesses Doing Business With, Attach Proof Of The Three (3) Top Major Suppliers Mentioned Below

Number Of Your Service Providers

Number Of BEE Businesses In Your List Of Service Providers

Details Of Your Top Three Major Suppliers:

Name Of Business

Name Of The Owner

Contact Number

Street Address

Service/Goods Procured

Upload Proof Of Supplier

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Trade Refferences(Please list at least 3 trade references from recent contracts awarded to you)

Client

Contact Person And Contact Number

Contract Description

Contract Value In Rands

ZAR

Project Duration

Year

Section B Financial Information

Banking Details

Bank Name

Branch Code

Branch Name

Account Type

Bank Account Number

Name Of Account Holder

Signed By:

Initials And Surname

Authorised Signature

Date

Text

Who Hereby Warrants That He / She Is Duly Authorised To Sign This Form On Behalf Of

Text

Declaration Of Service Provider's Past Supply Chain Management Practices

1 This serves as a declaration to be used by institutions in ensuring that when goods and services are being procured, all reasonable steps are taken into combat the abuse of the supply chain management system

2 The service of any service provider may be disregarded if that service provider or any of its directors have-

a. abused the institution's supply chain management system

b. committed fraud, corruption or any other improper conduct in relation to such system; or

c. failed to perform on any previous contract

3 In order to give effect to the above, the following questionnaire must be completed and submitted with the bid

3.1 Is the service provider or any of itys directors listed on the National Treasury's database as companies or persons prohibited from doing business with the public sectorYesNo

3.1.1 If So, Furnish Particulars

3.2 Was the service provider or any of its directors convicted by a court of law (including a court outside of the Republic of South Africa) for fraud or Corruption during the pastb five years?YesNo

3.2.1 If So, Furnish Particulars:

3.3 Was any Contract between the service provider and any organ of the state terminated during the past five years on account of failure to perform on or comply with the contract?YesNo

3.3.1 If So, Furnish Particulars

Certification

I, THE UNDERSIGNED (FULL NAME)

Signature

Date

Position

Name Of Service Provider

who hereby warrants that he / she is duly authorised to sign this form on behalf of:

Declaration Of Interest

1. Any legal person, including persons employed by the State, or persons who act on behalf of the state or persons having kinship with persons employed by the State, including a blood relationship, may make an offer or offers in terms of the invitation to provide a service. In view of possible allegations of favouritism, should the resulting service, or part thereof, be awarded to persons employed by the State, or to persons who act on behalf of the State, or to persons connected with or related to them, it is required that the service provider or his authorised representative shall declare his position visa-vis the evaluating authority and/or take an oath declaring his interest,

Where –

The service provider is employed by the State or acts on behalf of the State; - The legal person on whose behalf the application form is signed, has a relationship with person/ a person who is/are involved with the evaluation of the application, or where it is known that such a relationship exists between the person / persons for or on whose behalf the declarant acts and performs who are involved with the evaluation application. In order to give effect to the above, the following questionnaire shall be completed and submitted with the application.

2 Are you or any person connected with the service provider, employed by the State, or in a Public TVET or CET College?YesNo

2.1 If so, state particulars

3 Do you, or any person connected with the service provider, have any relationship (family, friend, other) with a person employed in the department concerned or with the State Tender Board or its administration, or in a Public TVET or CET College and who may be involved with the evaluation or adjudication of this application?YesNo

3.1 If so, state particulars

4 Are you, or any other person connected with the service provider, aware of any relationship (family, friend, other) between the service provider and any person employed by the department concerned, State Tender Board or its administration, or by a Public TVET or CET College, who may be involved with the evaluation or adjudication of this application?YesNo

4.1 If so, state particulars

Signed By

Name Of Declarant

Signature Of Declarant

Date

Position Of Declarant

Name Of Company

who hereby warrants that he / she is duly authorised to sign this form on behalf of

CETC Suppliers Database Application Form

Human Resource Development:

Details Of BBBEE Businesses Doing Business With, Attach Proof Of The Three (3) Top Major Suppliers Mentioned Below

Section B Financial Information

Banking Details

Please Select Your Organization's Types Of Commodities Or Services Rendered

Declaration Of Service Provider's Past Supply Chain Management Practices

1 This serves as a declaration to be used by institutions in ensuring that when goods and services are being procured, all reasonable steps are taken into combat the abuse of the supply chain management system

2 The service of any service provider may be disregarded if that service provider or any of its directors have-

a. abused the institution's supply chain management system

b. committed fraud, corruption or any other improper conduct in relation to such system; or

c. failed to perform on any previous contract

3 In order to give effect to the above, the following questionnaire must be completed and submitted with the bid

Where –

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