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					ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM

ILEMBE DISTRICT MUNICIPALITY ILEMBE-UMASIPALA WESIFUNDA PO BOX 1788, KWADUKUZA, 4450

TEL: 032 – 4379300

FAX: 032 – 4379582

ACCREDITED SUPPLIER DATABASE REGISTRATION FORM
COMP ANY DETAILS NAME: __________________________________________ Name of business as registered with the Registrar of Companies/Close Corporations __________________________________________ Trading name if different from above __________________________________________ Registration no as registered with the Registrar of Companies/Close Corporations (Please attach certified copy of registration documents)

TRADING NAME:

COMPA NY REG. NO:

WATER ACC NO: __________________________________________ If trading or residing within Ilembe District If trading or residing outside Ilembe District please attach a copy of the latest utility bill LEVIES ACC NO: VAT RE G. NO: __________________________________________ __________________________________________

INCOME TA X NO: __________________________________________ Please attach a copy of the latest valid tax clearance certificate PHYSICAL ADDRESS: __________________________________________ __________________________________________ POSTA L ADDRESS: __________________________________________ __________________________________________

CONTACT DETAILS CONTACT PE RSON: CONTACT TE L NO: ________________________________________ _________________ (CELL) _________________ (H) ____________ (W) _________________ (F) _______________________ (EMA IL A DDRESS)

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ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM PREFERE D ME THOD OF COMMUNICA TION: BANKING DETAILS I/We hereby request and authorise Ilembe District Muni cipality to pay any amounts that are due to me/us into my/our bank account held at the below mentioned financial institution. This authority will remain in force until such time it is cancelled by me/us giving (30) days written notice by prepaid registered post.

□ EMAIL □ FAX □ POST (INDICATE WITH A TICK)

____________________ Initial and Surname

__________________ Authorised Signature

______________ Date

NAME OF BANK: NAME OF BRA NCH: BRANCH CODE:

_________________________________ _________________________________ _________________________________

NAME OF ACCT HOLDER: ______________________________ (Name under which account is operated) ACCOUNT NUMBER: ACCOUNT TYPE: _________________________________

□ CURRE NT ACCOUNT □ SAVINGS ACCOUNT □ TRA NSMISSION ACCOUNT □ CHEQUE ACCOUNT □ OTHER (P LEASE SPECIFY) ___________________
DE TAILS OF BANK OFFICIA L: _________________ NAME: ____________________________________ DA TE RECE IVED: ___________________________ SIGNA TURE: _______________________________

Bank stamp certifying the above bank account details as correct

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ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM

BUSI NESS DETAILS Busine ss Type (Please tick appropriate box)

□ Close Corporation □ Private Company (Pty) Ltd □ Public Company □ Partnership □ Sole Trade/Propriet or □ Trust □ Section 21 Company □ Consortium or Joint Venture
CLASSIFICATION OF BUSINESS AND CATEGORY Please note: this section is compulsory (Please refer to Annexure A)

AREA OF BUSINESS

CATEGORY

TYP E OF FIRM AND SUPPLI ER CLASSIFICATION (Please tick the appropriate box) Supplier classi fication

□ Micro □ Very Small □ Small □ Medium □ Other (specify) ___________________

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ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM Sector or Subsector in accordance with the standard Industrial Classi fication Manufacturing Size of Class The total full-time equivalent of paid employees Total turn-over Total gross asse t value (fixed property excluded)

Medium Small Very small Micro Medium Small Very small Micro

200 50 20 5 200 50 20 5 200 50 20 5 200

R51m R13m R5m R0.20m R51m R13m R5.10m R0.20m R26m R6m R3m R0.20m R39m

R19m R5m R2m R0.10m R19m R5m R1.90m R0.10m R5m R1m R0.50m R0.10m R6m

Electricity, gas and water

Construction

Medium Small Very small Micro Medium

Retail and Motor Trade and Repair Services

Small Very small Micro Wholesale Trade, Commercial Agents and Allied Services Medium

50 20 5 200

R19m R4m R0.20m R64m

R3m R0.60m R0.10m R10m

Small Very small Micro Catering, accommodation and other Trade Medium

50 20 5 200

R32m R6m R0.20m R13m

R5m R0.60m R0.10m R3m

Trans port, storage & Communications

Small Very small Micro Medium Small Very small Micro

50 20 5 200 50 20 5 200 50 20 5 200 50 20 5

R6m R5.10m R0.20m R26m R13m R3m R0.20m R26m R13m R3m R0.20m R13m R6m R1m R0.20m

R1m R1.90m R0.10m R6m R3m R0.60m R0.10m R5m R3m R0.50m R0.10m R6m R3m R0.60m R0.10m

Finance & Business Services

Medium Small Very small Micro

Community, social & personal services

Medium Small Very small Micro

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ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM

LOCATION OF THE ENTERP RISE (Tick the appropriate box)

□ Ilembe District Municipality Area □ Kwazulu Natal □ Other ____________ □ Supplier □ Main Contractor □ Sub-contractor □ Labour-only Contractor □ Consultant □ Manufacturer □ Professional Services □ Education, Development & Training
Annual Turnover: ______________________ TYP E OF FIRM (Please tick appropriately)

DETAILS OF P ROFESSIONAL AFFILIATION OR REGULATORY BODY Institute/Profe ssional Body/Regulatory Body Registration No Profe ssional Insurance Indemnity No

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ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM

PREVIOUS BUSINESS INFORMATION Did the business exist under another name previously?

□ YES

□ NO (Tick one)

If “yes” what was the previous name? ____________________________________ Please state the reasons for the name of the change ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

DETAILS OF P REVIOUS OWNERS/PARTNERS/MEMBERS/SHAREHOLDERS

NAME

TITLE

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ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM

OWNERS/SHAREHOLDERS/MEMBERS/TRUSTEES Full Names ID NO SA Citizen (Yes/NO) Capacity (Member, shareholders etc) % Ownership Male/ Female Handicapped (Yes/No) HDI Status Yes/No Race (W/C/I/A) % of time devoted to business

Definition of ‘HDI’ & “youths ” – Historically Disadvantaged Individuals An HDI is defined in terms of Section 1(h) of the P referential Procurement Policy Framework Act 2000 (Act 56 of 2000) as being a South African Citizen: 1. 2. 3. 4. Who due to the apartheid policy that had been in place, had no franchise in national elections prior to the introduction of the Constitution of S outh Africa 1983 (Act no.110 of 1983) or the Constitution of the Republic of South Africa 1983 (Act No. 200 of 1983) (The Interim Constitution) and/or who is female/male, and/or who has a disability provided that a person who obtained South Africa citizenship on or after the coming to effect of the Int erim Constitution, is not deemed to be an HDI Generally accept ed definition of “Yout h” is any persons between the age of 18 and 35 years.

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ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM DECLARATION: CONFLI CT OF INTEREST Are any members or shareholders of the business: a) employed by Ilembe District Municipality; or b) in the service of the state?

□ Yes
a)

□ No
a member of i) ii) iii) any municipal council; any provincial legislature; or the National Assembly or the National Council of Provinces;

NOTE: “in the servic e of the state” means –

b) c) d)

a member of the board of directors of any municipality entity; an official of any municipality or municipal entity; any 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) a member of the accounting authority of any national or provincial public entity; or an employee of Parliament or a provincial legislature.

e) f)

If “YES” please state the nature if the relationship

Employee Name: ________________________ Salary Number: _______________________

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ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM DECLARATION I/WE, THE UNDERS IGNED WHO WARRA NTS THA T I/WE ARE DULY AUTHORISED TO DO SO ON BEHALF OF THE ENTERP RISE, CE RTIFIES THA T THE INFORMA TION SUPP LIE D IN TERMS OF THIS DOCUMENT INCLUDING THE RE LEVANT A TTACHEME NT IS CORRE CT AND ACCURA TE AND ACK NOWLE DGE THA T: 1. 2. The enterprise will be required to furnish documentary proof requested to do so. If the information supplied is found to be incorrect, then Ilembe District Municipality may in addition to any remedies it may have: a) Disqualify the supplier/contractor for a particular bid/contract/project it may be considered for, or which had been awarded to the supplier/contractor; b) Recover from the contractor/supplier all costs, losses or damages incurred by Ilembe District Municipality as a result of the breac h of contract ; c) De-register the supplier from the accredited suppliers database; d) Take any other action as may be deemed necessary.

Full Names: ID Number: Signature: Date: Duly authorised on behalf of: Address:

__________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________

Telephone no:

__________________________________________________

Signed and affirmed before me at _________________________________ on this __________day of _________________ year __________________ by the depondent who has acknowledged that he/she knows and understands, the contents of this document, and he/she has acknowledged that he/she regards the affirmation to be binding on his/her conscience. ______________________________ Commissioner of Oaths _______________________________ Full Name _________________________ Capacity

________________________________________________________________________ Business address
NOTE: Both the depondent and the Commissioner of Oath m ust initial all pages of the Application form

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ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM ANNEXURE “A” 1. ADMI NISTRATION                                    Stationery ….. Printing…. Cleaning materials … Cleaning equipment… Vehicle maintenance and repairs… Office maint enance… Office equipment …. Catering … Office furniture… Computer hardware, software, development Network solutions etc… Travel agents, conference facilities, Accommodation and car rental…. Courier services ….. Media/publicity/advertising… Promotional mat erials…. Vehicle purchasing… Office maint enance…. Insuranc e brokers… Computer accessories…. Cons umables…. Entertainment…. Publishing…. Books Fuel, oil, tyres and gas Auctioneers Security Services Pest control Painting Plumbing Electrical Repairs Renovations Fumigation Carpet Cleaning Car Wash

□ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □
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2. HUMAN RESOURCES      Training and development ….. Organisational development…. Legal compliance … Job evaluation… Industrial relations training…

ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM 3. SOCIAL S ERVI CES      Healt h, safety and environment ….. Healt h servic es…. Medical Consumables … Medical instruments… Linen, pillows and blankets…

□ □ □ □ □

4. ACCOUNTING & FINANCE        Corporate Finance….. Financial Management…. Tax Cons ulting Services … Audit consulting services… Payroll systems consulting… Financial systems consulting… Banking Services…

□ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □
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5. CIVIL          Sockets ….. Valves…. Wire … Tees, couplings, ferrules etc… Tubes… Hose taps ….. Packings…. Water meters … Miscellaneous water equipment…

6. GENERAL           Bolts & nuts ….. Building material…. Nails … Locks… Cement… Tools ….. Pipes & accessories…. Window glass … Corrugated iron… Other specify…

7. TECHNICAL/PROFESSIONAL SERVICES   Building contractors… Cons ulting engineers…

ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM             Electrical engineers … Mechanic al engineers… Land surveyors ….. Architects…. Water treatment chemicals … Telemet ry systems & maintenance… Plant hire… Safety equipment… Town & development planning ….. Environmental…. Strategic planning … Economic development…

□ □ □ □ □ □ □ □ □ □ □ □

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ILEMBE DISTRICT MUNICIPALITY – REGISTRATION FORM

ANNEXURE “B” Required document checklist Please ensure that all documentation listed below is attached (where applicable) to the registration form.

Document Name

Attached

Original Tax Clearance Certificate Company Registration Certificate Most recent municipal accounts for your business location or your personal residence i.e. rates, water, refuse, electricity (if applicable) and levy registration confirmation letter. Banking details certified by bank (page 2)

□ □ □ □

FOR OFFICE USE ONLY RECEIPT NO: _______________________________________ CAPTURED BY: _____________________________________ CHECKED BY: ______________________________________ VERIFI ED BY: ______________________________________

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