Supplier Registration Application Form 2012 by 667pn8

VIEWS: 21 PAGES: 9

									                                                            Enquiries: James Mosoma
                                                            E-mail: jmosoma@npa.gov.za
                                                            Tel No: 012 845 6065
                                                            Fax No: 012 843 2643

                        SUPPLIER DATABASE REGISTRATION



NAME OF SERVICE PROVIDER: ________________________________________
                    (To be completed by supplier)

                   FOR OFFICIAL PURPOSES

Name of Evaluator from SCM: ____________________________________________

Persal No: ____________________               Signature: ____________________

Date:

Entity Maintenance No: __________________________

Captured by: _____________________     Persal No: __________________________

Signature: _______________________     Date: ______________________________


        APPLICATION ACCEPTED            APPLICATION REJECTED



                      NPA SUPPLIER
                        NUMBER


Verified & Captured on Supplier Database by: ____________________________

Persal No: ____________________        Signature: _______________________

Date:
TO ALL SUPPLIERS SEEKING REGISTRATION AS A PREFERRED SUPPLIER ON THE NATIONAL
PROSECUTING AUTHORITY DATABASE

Important information pertaining to registration as a prospective supplier: In order to
comply with Treasury Regulations 16A, the department developed a supplier database.

The purpose of this database is to give all prospective suppliers opportunity to submit
quotations to the department and to enhance transparency and equity.

Preference will be given to the registered service providers but suppliers who are not
registered will be excluded from quoting for the supply of goods and services.

The original Tax Clearance, Cipro certificate and ID copies of a contact person must be
submitted together with the supplier registration form

Suppliers without a valid tax clearance certificate must complete the SARS application form
and forward it to the South African Revenue Services.

Suppliers will not be notified of the outcome but will be advised of the outcome if
telephonically requested.

The NPA reserves the right to accept or reject any application without being obliged to give
any reasons in this respect.

Suppliers must comply with all the registration criteria for registration to be finalized.

N.B. Failure to comply with any of the above may result in an application being declined.

Questions can be directed to Mr. James Mosoma on 012 845 6065 or via email to:
jmosoma@npa.gov.za

Supplier registration forms should be sent to:        National Prosecuting Authority
                                                      VGM Building
                                                      Supply Chain Management
                                                      Private Bag X752
                                                      Pretoria
                                                      0001

Or hand delivered to:                                 National Prosecuting Authority
                                                      VGM Building
                                                      Supply Chain Management
                                                      140 Westlake Avenue
                                                      Weavind Park
                                                      Silverton
                                                      0127
IMPORTANT NOTES
Please Read carefully

To be completed by the applicant seeking registration as an approved service provider
The application form must be completed in full and be signed; failure to do so will result in
the application being declined
A company profile must accompany the registration form but will not be accepted as
substitute for the application form- all fields on the application form MUST be completed
Applicants must submit all contact details including a fax number, failure to do so will result
in the application being excluded
It should be noted that National Prosecuting Authority reserves the right to accept or reject
any application without being oblige to give any reasons;
A maximum of FOUR commodities must be reflected on the application form. Reflecting
more than four commodities will nullify the application;
A company registration certificate from CIPRO and the BEE Certificate MUST be included in
the application package

SUPPLIER DETAILS(all fields are mandatory)

Name of the Supplier:

……………..………………………………………………………………………………………………………………………………

Physical address:

…………..…………………………………………………………………………………………………………………………………

………..……………………………………………………………………………………………………………………………………

Postal address:

……….………………………………………………………………………………………………………………………………………

Contact Person          :……………………………………………………………………..

Telephone numbers :……………………………………………………………………..

Mobile numbers          : …………………………………………………………………….

Fax numbers             : …………………………………………………………………….

E-mail address          : …………………………………………………………………….

Identification number : …………………………………………………………………….
Company/ Close Corporation Registration Number



Income tax number:



Vat number:



Company/Supplier Classification: (Please tick the relevant box)
ISO    Importer Services Manufacturer Distributor Exporter Sales      Repairer
Listed

SUPPLIER GROUPING DETAILS: (Please mark the relevant box with an X)

 1      Government/Parastatal
 2      Public Company
 3      Private Company
 4      Close Corporation
 5      Joint Venture
 6      Consortium
 7      Sole Proprietor
 8      Foreign Company
 9      Partnership
 10     Trust
 11     Section 21 Company
 12     Other

List of Directors/owners/partners

Name                 Position          Shareholding %   Identity      Nationality
                                                        number
Declaration of interest

Name                                     Position                            Directorate in National
                                                                             office/Regional office




SMME status of your enterprise
   Please use this table to determine the SMME status of your enterprise
   Please the relevant box in each column

     A. Sector           B. Full-time paid employees    C.     Annual       Turnover   D. Total Gross assets value
                                                        (millions)                     (property         excluded,
                                                                                       millions)

                         Mediu    Smal    Smal   Micr   Mediu   Smal    Smal   Micr    Mediu    Smal   Smal   Micr
                         m        l       l      o      m       l       l      o       m        l      l      o
Accommodation            100      50      10     5      10      5       1      0.15    2        1      0.2    0.1

Catering                 100      50      10     5      10      5       1      0.15    2        1      0.2    0.1

Commercial Agents        100      50      10     5      50      25      5      0.15    8        4      0.5    0.1

Communication            100      50      10     5      20      10      2      0.15    5        2.5    0.5    0.1

Community & Social       100      50      10     5      10      5       1      0.15    5        2.5    0.5    0.1
services
Construction             200      50      20     5      20      5       2      0.15    4        1      0.4    0.1

Finance & Business       100      50      10     5      20      10      2      0.15    4        2      0.4    0.1
services
Manufacturing            200      50      20     5      40      10      4      0.15    15       3.75   1.5    0.1

Personal services        100      50      10     5      10      5       1      0.15    5        2.5    0.5    0.1

Retail & motor trade     100      50      10     5      30      15      3      0.15    5        2.5    0.5    0.1

Repair/Allied services   100      50      10     5      30      15      3      0.15    5        2.5    0.5    0.1

Storage                  100      50      10     5      20      10      2      0.15    5        2.5    0.5    0.1

Transport                100      50      10     5      20      10      2      0.15    5        2.5    0.5    0.1

Wholesale trade          100      50      10     5      50      25      5      0.15    8        4      0.5    0.1

Other trade              100      50      10     5      10      5       1      0.15    2        1      0.2    0.1



SMME STATUS OF YOUR ENTITY Please  the relevant box
(According to SMME table) (Compulsory)

Micro
Very Small
Small
Medium
Large
Points awarded for B-BBEE Status Level of Contribution

In terms of Regulation 5 (2) and 6 (2) of the Preferential Procurement Regulations,
preference points must be awarded to a bidder for attaining the B-BBEE status level of
contribution in accordance with the table below:

    B-BBEE Status Level of               Number of points                Number of points
        Contributor                     (80/20 system) for              (90/10 system) for
                                      R 30 000 to R 1 000 000         amounts over R 1 000 000
            1                                   20                              10
            2                                   18                              9
            3                                   16                              8
            4                                   12                              5
            5                                    8                              4
            6                                    6                              3
            7                                    4                              2
            8                                    2                              1
 Non-compliant contribution                      0                              0

A bid will not be disqualified from the bidding process if the bidder does not submit a certificate
substantiating the B-BBEE status level of contribution or is a non-compliant contributor. Such a
bidder will score zero (0) out of a maximum of 10 or 20 points respectively for B-BBEE.
Bidders who qualify as EMEs in terms of the B-BBEE Act must submit a certificate issued by an
Accounting Officer as contemplated in the CCA or a Verification Agency accredited by SANAS or a
Registered Auditor. Registered auditors do not need to meet the prerequisite for IRBA’s approval for
the purpose of conducting verification and issuing EMEs with B-BBEE Status Level Certificates.

BID DECLARATION
Bidders who claim points in respect of B-BBEE Status Level of Contribution must complete the
following:

B-BBEE STATUS LEVEL OF CONTRIBUTION CLAIMED IN TERMS OF TABLE ABOVE

B-BBEE Status Level of Contribution: …………. = ……………(maximum of 20 points)

(Points claimed must be in accordance with the table reflected above and must be substantiated by
means of a B-BBEE certificate issued by a Verification Agency accredited by SANAS or a Registered
Auditor approved by IRBA or an Accounting Officer).

In terms of Section 38 of the PFMA the accounting officer of a department must ensure that the
department has and maintains an appropriate procurement and provisioning system which is fair,
equitable, transparent, competitive and cost-effective.
DECLARATION

Verification of information supplied in this document, including attached documents:

I/We, the undersigned, warrant that he/she is duly authorized to do so on behalf of the supplier,
certifies that the information supplied is correct and accurate and acknowledge that:

If found that the information supplied is incorrect the National Prosecuting Authority will
disqualify and remove the supplier from our Database permanently.

   Name In print             Signature              Designation                Date




TERMS AND CONDITIONS

      The National Prosecuting authority cannot guarantee business opportunities. All
       procurement will be subject to the departmental SCM policy, the general conditions of
       contract, and applicable legislation.
      All suppliers will be subjected to regular performance service review and could be
       deregistered if service levels are not maintained.
      The validity period of a quotation must be at least 30 (thirty) days
      Certified documents: Please ensure that a Commissioner of Oaths has certified your
       company registration documents, and other documents
      Original Tax Clearance Certificate
      All shareholders/Directors/Members and in case of one-man concern, please furnish
       identity numbers plus copy of identity documents ID
      Verification information supplied will perform against third party source such as SARS,
       CIPRO, etc
      Please notify the Department immediately of any change to the provided information
      Please ensure all fields are completed. Incomplete application forms will not be
       processed.


Supplier Name: ________________________________________________________________


_____________________________________                         __________________________
Signature of Authorised Representative                        Signatory Name in Print

_____________________________________                         __________________________
Signatory capacity                                            Signatory ID Number


Signed at __________________________ on this ________ day of _________________ 20___
PLEASE CHOOSE ONLY A MAXIMUM OF FOUR (4) CATEGORIES
   LIST OF COMMODITIES (mark with x)

   ACCOMMODATION                                EXTENSION CORDS
   ADVERT PLACEMENTS: PRINT MEDIA               FACILITATION SERVICES
   ADVERTISING: RADIO & TELEVISION              FLAGS & MAPS
   ADVERTISING: PRINT MEDIA                     FRAMING SERVICES
   AIRCON INSTALLATION & REPAIRS                FRANKING MACHINE
   ANNUAL REPORTS: CONCEPT, DESIGN & LAYOUTS    FURNITURE REMOVAL
   ALARM SYSTEMS AND EQUIPMENT                  FURNITURE REPAIRS
   ARCHIVING SERVICES & SYSTEMS                 GRAPHIC DESIGN SERVICES
   ART & CRAFT MATERIALS                        INTERNET SERVICE PROVIDER
   ARTWORK & PAINTINGS                          IMAGING SERVICE
   ASSET MANAGEMENT SYSTEMS                     INTERIOR DECORATORS &DESIGN
   AUDIO VISUAL SYSTEM & EQUIPMENT              INTERPRETATION SERVICE
   AUDITING SERVICES                            KITCHEN APPLIANCE
   BADGES FOR CONFERENCES, EMBROIDERED          LIGHTS & FITTINGS
   BAGS FOR CONFERENCES/ TRAVEL.                LOCKSMITH SERVICES
   BANQUETING EQUIPMENT                         LOGO: DESIGN SERVICE
   BEVERAGES & ALCOHOL                          MARQUEE & CHAIRS: HIRING
   BINDING MACHINES & SERVICES                  NEWSPAPER SUPPLIERS
   BLINDS INSTALLATIONS & REPAIRS               OFFICE EQUIPMENT
   BUSINESS PLANS                               OFFICE FURNITURE
   CANTEEN EQUIPMENT                            OFFICE PLANTS
   CATERING                                     PA SYSTEMS: HIRING
   CABLING SYSTEM & MANAGEMENT                  PHOTOGRAPHERS
   CARPENTERS & CARPENTRY SERVICES              PHOTOGRAPHIC EQUIPMENT
   CELLULAR TELEPHONES & REPAIRS                PRINTER REPAIRS
   CLEANING SERVICES & CHEMICAL/EQUIPMENT       PRINTING SEVICES: DESIGN
   CLOTHING & UNIFORM                                           BANNERS
   COFFEE & VENDING MACHINE                                     BOARDS
   COMPUTERS/ LAPTOPS:                                          BRAILLE
              COMPUTER EQUIPMENT                                BUSINESS CARDS
              COMPUTER CONSUMABLES                              BROCHURES
   COMPUTER SOFTWARE: INSTALLATION & LICENSES                   NEWSLETTER
   COMPUTER REPAIRS, SERVICES & MAINTENANCE                     PAMPHLETS
   CONFERENCE FACILITIES & VENUES                               PENS
   CONSULTING SERVICES                                          T-SHIRTS
   COPYWRITING SERVICES                         PROFESSIONAL SERVICES
   CORPORATE GIFTS & PRODUCTS                   PROMOTIONAL ITEMS
   CROCKERY & CUTLERY                           RECRUITMENT AGENCIES
   DATA ANALYSIS                                SOUND & RECORDING EQUIPMENT
   DATA CAPTURING SERVICES                      SANDBLASTING
   DEVELOPMENT: DATABASE                        STATIONERY
   DICTAPHONE MACHINE                           SUBSCRIPTION/ MAGAZINE
   DIGITAL CAMERAS                              TRANSCRIPTION SERVICES & RECORDING
   DSTV INSTALLATION & REPAIRS                  TRANSLATION SERVICES
   EDITING OF DOCUMENTS SERVICES                TRAVEL AGENTS
   ELECTRICAL APPLIANCES                        UPHOLSTERERS
   EMBOSSING SERVICES                           VENDING MACHINE
   EMBROIDERY SERVICE                           VENUE
   ENGRAVING SERVICES                           VETTING SERVICES (CITIZENSHIP, FINANCIAL – INC DEBT & PROPERTY, CRIMINAL)
LIST OF COMMODITIES (mark with x)
ENTERTAINMENT SERVICES:(PERFORMERS)   VIDEO MACHINE
EVENT COORDINATORS                    WEB PAGE DESIGN & MAINTENANCE
EVENT MANAGEMENT                      WORKSHOP FACILITATION & EQUIPMENT
EXHIBITION                            WRITING SERVICES (ARTICLES & EDITORIAL)

								
To top