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MODIMOLLE LOCAL MUNICIPALITY

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 MODIMOLLE LOCAL
   MUNICIPALITY




REGISTRATION FORM



Supplier and Service
Provider Database
                                                                                  2


MODIMOLLE LOCAL MUNICIPALITY

 APPLICATION FORM TO REGISTER IN THE SUPPLIER
       AND SERVICE PROVIDER DATABASE

 ALL QUESTIONS TO BE ANSWERED IN DETAIL (PLEASE PRINT OR TYPE

            ENSURE THAT THE QUESTIONNAIRE IS SIGNED


1.   SECTION 1 : PARTICULARS OF THE ORGANISATION

     Please note that all information will be treated confidentially. Provide
     details regarding the organisation. Where organisation is a joint venture,
     the individual members of the joint venture are to separately provide
     information of their organisation.

     1.1   REGISTERD NAME OF THE ORGANISATION:




     1.2   TRADING NAME:




     1.3   CONTACT PERSON:




     1.4   POSTAL ADDRESS:




            POSTAL CODE:
                                                                3


1.5    PHYSICAL ADDRESS:




       POSTAL CODE:



1.6    TELEPHONE NUMBER:                FAX NUMBER:




1.7    CELL PHONE NUMBER:               E-MAIL ADDRESS:




1.8    TYPE OF ORGANISATION:
       (Certified copy of registration form must be attached)

       Close Corporation                   (Pty) Ltd Company
       Sole Trader                         Ltd Company
       Partnership                         Not Registered


1.9    COMPANY REGISTRATION NUMBER:




1.10   INCOME TAX REGISTRATION NUMBER:
       (Certified copy of registration form must be attached)




1.11   VAT REGISTRATION NUMBER:
       (Certified copy of registration form must be attached)
                                                                               4


2.   SECTION 2 : EVALUATION SECTION


     2.1   PLEASE INDICATE THE JURISDICTION OF INTEREST:

            CODE                     AREA                                     
            MLM  Modimolle Local Municipal Area
            LP   Outside Modimolle Local Municipal Area but in
                 Limpopo Province
            OLP  Outside Limpopo Province


     2.2   PLEASE INDICATE SIZE OF THE ORGANISATION BASED ON
           ANNUAL TURNOVER IN THE PAST THREE YEARS:

                                   TURNOVER                                    
            < R1 000 000
            R 1 000 001 - R 5 000 000
            R 5 000 001 - R10 000 000
            R10 000 001 - R20 000 000
            R20 000 001 - R30 000 000
            R30 000 001 - R40 000 000
            R40 000 001 - R50 000 000
            > R50 000 000


     2.3   PLEASE INDICATE THE YEAR THE ORGANISATION WAS
           ESTABLISHED:




     2.4   PLEASE INDCATE THE LEVEL OF OWNERSHIP OF YOUR
           ORGANISATION BY HISTORICAL DISADVANTAGED
           INDIVIDUALS (HDI) IN THE FORM OF PERCENTAGE:
           (Historically Disadvantaged Individual (HDI) means a South African
           citizen -

           (a)   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 the Republic of South Africa, 1983, (Act
                 No 110 of 1983) or the constitution of the Republic of South
                 Africa, 1983 (Act No 200 of 1993) ("the interim
                 Constitution"); and/or
           (b)   who is female; and/or
           (c)   who has a disability.
                                                                          5



                   HDI %              
           0%
           1% - 9%
           10% - 19%
           20% - 29%
           30% - 39%
           40% - 49%
           50% - 59%
           60% - 69%
           70% - 79%
           80% - 89%
           90% - 99%
           100%


     2.5   PLEASE PROVIDE DETAILS OF OWNERSHIP OF THE
           ORGANISATION BY LISTING NAMES OF DIRECTORS,
           SHAREHOLDERS, OWNERS AND PARTNERS INCLUDING
           THEIR OWNERSHIP PERCENTAGE:

           (If total number exceeds 20, please attach a separate list.)

NO         NAME                  ID NUMBER           CITIZENSHIP HDI %
                                                                 Y/N
 1
 2
 3
 4
 5
 6
 7
 8
 9
10
11
12
13
14
15
16
17
18
19
20
                                                            6


2.6   PLEASE PROVIDE TOTAL NUMBER OF STAFF MEMBERS:




2.7   PLEASE PROVIDE DETAILS ON THE CURRENT STAFFING IN
      THE ORGANISATION IN A FORM OF A PERCENTAGE:

          GRADE          % OF          % OF      % OF HDI
                        FEMALE       PEOPLE      STAFFING
                                       WITH
                                    DISABILITY
      DIRECTORS/
      PARTNERS/
      MEMBERS
      ASSOCIATES

      PROFFESIONALS

      TECHNICIANS

      ADMIN STAFF

      OTHER



2.8   PLEASE PROVIDE BUSINESS TYPE:


        CODE          DESCRIPTION                 

         CON    CONSULTING SERVICES

         TOR    CONTRACTOR

         SUP    SUPPLIER
                                                                      7


3.    SECTION 3 : AREA OF SPECIALISATION

      3.1   PLEASE INDICATE AREA OF INTEREST:

            (Please tick only one category)

             ACC    Accounting, Auditing &       Section 4.1 only -
                    Financial Services           Page 10
             CONFAC Construction,                Section 4.2 only -
                    Engineering Services         Pages 10 - 12
                    and Facilities
                    Management
             HR     Human Resources              Section 4.3 only -
                                                 Page 13
             IT         Business System and      Section 4.4 only -
                        Information Technology   Pages 14 - 15
             LEG        Legal                    Section 4.5 only -
                                                 Pages 15 - 16
             GEN        General                  Section 4.6 only -
                                                 Pages 16 - 17




     PLEASE REFER TO ATTACHED
       LISTS OF DISCIPLINES AND
     SPECIALITIES IN PAGES 10 - 17
       FOR THE COMPLETION OF
      SECTION 3.2 : DISCIPLINE OF
               INTEREST
                  AND
        SECTION 3.3 : SPECIALITY
                                                             8


3.2   PLEASE FILL IN THE DISCIPLINE OF INTEREST:

             DISCIPLINE CODE               DISCIPLINE NAME
                                                            9



3.3   PLEASE FILL IN SPECIALITY:

             SPECIALITY CODE       SPECIALITY DESCRIPTION
                                                                             10


4.   SECTION 4

     4.1   ACCOUNTING, AUDITING AND FINANCE SERVICES

           Discipline of Interest:

           (Please provide a list if discipline is not indicated below)

              DISCIPINE CODE                      DISCIPLINE NAME
            ACCNT                    Accounting
            AUDTRN                   Audit Training
            AUDT                     Auditing
            FINSER                   Finance Services
            OTHER
            (Please specify)

           Speciality:

           (Please provide a list if discipline is not indicated below)

             SPECIALITY CODE                    DISCIPLINE NAME
            CNTRSK                   Control Risk Assessment Consulting
            FINSERV                  Financial System management
            INTADT                   Internal Audit Training
            RSKMAN                   Risk Management Consulting
            SEMINR                   Seminars Related to Internal Audit
            OTHER
            (Please specify)


     4.2   CONSTRUCTION, ENGINEERING SERVICES AND FACILITIES
           MANAGEMENT SYSTEMS

           Discipline of Interest:
           (Please provide a list if discipline is not indicated below)

               DISCIPINE                        DISCIPLINE NAME
                 CODE
            AGRECO                Agriculture Economist
            AGRENG                Agriculture Engineers
            AIRCON                Air conditioning
            ARCH                  Architects
            AUCTN                 Auctioneers
            BLDCON                Building Contractors
            CVLCON                Civil Contractors
            CVLENG                Civil Engineers and Structural Engineers
                                                                 11


 DRAP                  Draughts Persons
 EQUIP                 Construction Equipments
 ELCCON                Electrical Contractors
 ELCENG                Electrical Engineers
 ELTENG                Electronic Engineers
 ENVMAN                Environmental Specialists
 FACMAN                Facilities Management and Building Systems
 INDENG                Industrial Engineers
 INTDSG                Interior Designers
 LANSUR                Land Surveyors
 MNTMAN                Maintenance Manager
 MECCON                Mechanical Contractors
 MECENG                Mechanical Engineers
 OSPLNA                Office space Planners architects
 PLUMB                 Plumbers
 PRJMAN                Project Managers
 PROCON                Property Consultants
 PRODEV                Property Developers
 PROPEV                Property Evaluators
 QTYSUR                Quantity Surveyors
 REFCON                Refrigeration Contractors
 SPCENG                Specialist Consulting Engineers
 STRCAB                Structural Cabling
 STRENG                Structural Engineers
 SSTCON                Structural Steel Contractors
 TRP                   Town and Regional Planners
 TRAIN                 Training / Organisation Body
 OTHER
 (Please specify)

Speciality:
(Please provide a list if discipline is not indicated below)

   SPECIALITY                        DISCIPLINE NAME
      CODE
 AIRSYS                Air Conditioning Building Management Skills
 AIRHND                Air Handling Units
 AUDIO                 Audio Systems
 BRILAY                Bricklayers
 CABLES                Cabling
 CPJOIN                Carpentry and Joinery
 CCVTV                 CCTV
 CELPRT                Ceiling and Partitions
 CLNSER                Cleaning Services
 COMBLD                Commercial / Industrial Building
                                                    12


COMENG   Communication Engineering
CMPNET   Computer Networking
CONMAT   Construction Materials
CONREP   Concrete Repairs Specialist
CTRADM   Contract Administration
COLTOW   Cooling Towers
CSTENG   Cost Engineers
DEMDIS   Demolition and Dismantling Contractors
DEVSTR   Development Strategists
ELCSYS   Electrical Building Management Systems
ELQUIP   Electrical Equipments
ELTSYS   Electronic Building Management Systems
ESTATE   Estate Agents
FANAIR   Fan Air Terminal / Fan Coil Unit
FIREDT   Fire Detectors
FIREPR   Fire Protection
FLRCVR   Floor Coverings
FURNIT   Furniture Contractors
GLAZ     Glazing
HEAT     Heat Exchangers
HOUS     Housing
INDENG   Industrial Engineering
INSTAL   Installation of Furniture
INFRST   Infrastructure Development Engaged in Civil
         Projects
MECON    Mechanical Consumables
MECSYS   Mechanical Building Management Systems
MECDRS   Mechanical Doors - Vaults, Revolving, Roll-up
MECEQP   Mechanical Equipment
NEWBLD   New Buildings
PAINT    Painting
PFAEQ    Pipes, fittings and Equipments
PLUMB    Plumbers
RSDFLR   Raised Floor Contractors
RECCHL   Reciprocating Chillers
RENOV    Renovation and Restoration
SCAFF    Scaffolding Contractors
SWRSYS   Sewer Systems
SHLV     Shelving and Racking
SHPFIT   Shop Fitters
SIGN     Signage
STRCAB   Structural Cabling
SSTCON   Structural Steel Contractors
TRFENG   Traffic Engineer
TRAING   Training / Organisation Body
                                                                        13


       URBDSG                Urban Designers
       VENT                  Ventilation Contractors
       WTRPRF                Water Proofing Specialists
       WTRTRT                Water Treatment - Hi-Tech Building
       OTHER
       (Please specify)


4.3   HUMAN RESOURCES

      Discipline of Interest:
      (Please provide a list if discipline is not indicated below)

           DISCIPINE                       DISCIPLINE NAME
             CODE
       LABREL                Labour Relations
       MEDSRV                Medical Services
       RECRT                 Recruitment
       RESCH                 Research
       TRNING                Training
       OTHER
       (Please specify)

      Speciality:
      (Please provide a list if discipline is not indicated below)

         SPECIALITY                        DISCIPLINE NAME
           CODE
       ADVERT                Advertising
       CLMSTD                Climate Studies
       CLNCAL                Clinical
       COMBEN                Compensation and Benefit
       COUNCE                Counselling
       FACTRN                Training Facilitators
       HRSYS                 Human Resource Systems
       LABMAT                Labour Relations Matters
       MGTDEV                Management Development Training
       PERREL                Personal Relations
       PRFMAN                Performance Management
       PSCASS                Psychological Assessment and Counselling
       RCTAGN                Recruitment Agencies
       SKLADT                Skills Audit
       SKLTRN                Skill Training
       SPCTRN                Specialised Training
       TECDEV                Technical Development Training
                                                                     14


       WELMGT                Wellness Management
       OTHER
       (Please specify)

      IF TECHNICAL DEVELOPMENT TRAINING PLEASE SPECIFY
      UNDER "OTHER".


4.4   BUSINESS SYSTEMS AND INFORMATION TECHNOLOGY

      Discipline of Interest:
      (Please provide a list if discipline is not indicated below)

           DISCIPINE                       DISCIPLINE NAME
             CODE
       BUS                   Business Solution
       HWP                   Hardware Products
       PRT                   Partnership & Certification
       SEC                   Security Systems
       SPCXPT                Specialist Expert (Specify)
       SWP                   Software Products
       TRN                   Training Services
       OTHER
       (Please specify)

      Speciality:
      (Please provide a list if discipline is not indicated below)

         SPECIALITY                        DISCIPLINE NAME
            CODE
       APSW                  Application Software
       BOS                   Back Office Software
       CLINFR                Client Infrastructure
       CLPERI                Client Peripherals
       CLSW                  Client Software
       DEVSW                 Development Software
       DISREC                Disaster Recovery
       INFMAN                Information
       INFSEC                Information Security
       ITAUD                 IT Auditing
       ITPRJ                 IT Project Management
       LNINFR                LAN Infrastructure
       LNPERI                LAN Peripherals
       NWINFR                Network Computing Infrastructure
       NWMAN                 Network Management
                                                                       15


       TELCOM                Telecommunication
       VOINFR                Voice Infrastructure
       WNINFR                WAN Infrastructure

       HPPART                HP-Partnership
       CISCO                 CISCO-Partnership
       NORTEL                Nortel-Partnership
       MSPART                Microsoft-Partnership
       NOVELL                Novell-Partnership
       IBM                   IBM-Partnership
       A+                    A+
       N+                    N+
       MCSE                  MCSE
       MCSD                  MCSD
       CNI                   CNI
       CNE                   CNE
       MCNE                  MCNE
       CCIE                  CCIE
       CLP                   CLP
       OTHER
       (Please specify)


4.5   RISK MANAGEMENT

      Discipline of Interest:
      (Please provide a list if discipline is not indicated below)

          DISCIPINE                        DISCIPLINE NAME
            CODE
       EXTAT                 External Firms of Attorneys
       EXTCOU                External Counsel
       INSBR                 Insurance Broking Companies (Local and
                             Offshore)
       INSREIN               Insurer and Re-insurers (Local and Offshore)
       LOSS                  Loss Adjusters and Assessors
       RSKMAN                Risk Management Consultants
       VALCT                 Valuators and Actuaries
       OTHER
       (Please specify)
                                                                          16



      Speciality:
      (Please provide a list if discipline is not indicated below)

         SPECIALITY                        DISCIPLINE NAME
           CODE
       ASSET                 Assets all Risks / Property Loss Insurance
       AGGPTC                Aggregate Protection Insurance
       BANKBND               Bankers Blanket Bond and Electronic
                             Computer Crime Insurance
       CONWRK                Contract Works
       COPTR                 Corporate Travel
       DIRINS                Directors and Officers Legal Liability
                             Insurance
       DISINS                Disability Top-Up Insurance
       EMPLOY                Employment Practices Liability
       GUARNT                Product Guarantee and Recall Expenses
                             Insurance
       HAZOCC                Hazardous Occupations
       HOUINS                House Owners Insurance
       KEYINS                Key Man Insurance
       LIAINS                General Liability Insurance
       LIFINS                Group Life Insurance
       MARINS                Marine Insurance
       MRTGAG                Mortgage Bond Group Life Insurance
       MTRINS                Motor Vehicle Insurance
       PERACC                Group Personal Accident
       POLREM                Pollution and Remedial Liability Insurance
       PRFIND                Professional Indemnity
       RETFND                Retirement Fund Errors and Omissions and
                             Crime
       RETIRE                Post-Retirement Medical Aid Contribution
                             Deficit Insurance
       OTHER
       (Please specify)


4.6   LEGAL

      Discipline of Interest:
      (Please provide a list if discipline is not indicated below)

         DISCIPINE                         DISCIPLINE NAME
           CODE
       CDCOMM                Chairperson of Disciplinary Committee
                                                                     17


       CIVMAT                Civil Matters
       CONV                  Conveyancing
       DEBCOL                Debt Collection
       LEGOP                 Legal Opinions
       MDCOMM                Member of Disciplinary Committee


4.7   LOGISTICS

      Discipline of Interest:
      (Please provide a list if discipline is not indicated below)

           DISCIPINE                       DISCIPLINE NAME
             CODE
       CAFKTC                Cafeteria and Kitchen
       CATACC                Catering and Accommodation
       CLEANSV               Cleaning Services
       CLOTHS                Clothing
       HOSPID                Hospitality
       OFFEQP                Office Equipment
       PROCON                Protocol and Conferences
       SERV                  Other Services
       STNRY                 Stationary
       TRANST                Transport and Storage
       OTHER
       (Please specify)


      Speciality:
      (Please provide a list if discipline is not indicated below)

         SPECIALITY                        DISCIPLINE NAME
           CODE
       AIRBOOK               Travel Air Tickets Bookings
       ARTMUS                Art and Museum Curators
       CAFCON                Cafeteria Consumables
       CAHIR                 Car Hire
       COMCON                Computer Consumables
       COPCTH                Corporate Clothing
       COURSV                Courier Services
       ELETR                 Electronic Equipment
       EVENT                 Event managers or Co-ordinators
       GRDMNT                Garden Maintenance
       GENCLN                Cleaning Services and General Maintenance
       GYMEO                 Gym Equipment
                                                                       18


GYMMNT             Gym Maintenance
KITCHN             Kitchen Equipment
LINGUI             Linguists (specify)
OFFCON             Office Consumables
PNLBTG             Panel Beating
PRTCTC             Protective Clothing
SLKGRD             Silk Plan Maintenance
SPCRES             Specialised Restaurant
TOUROP             Tour Operator
TVLAGN             Travel Agencies
VEHMNT             Vehicle Maintenance
OTHER
(Please specify)




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