Questionnaire for Supplies - Goods (2)

8/3/2019 Questionnaire for Supplies - Goods (2)

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SUPPLIER DATABASE

REGISTRATION

QUESTIONNAIRE SUPPLIES - GOODS

Name of company

Town / City

IDT Internal Staff

Submitted by .Ext..

The supplier will be used for: (please mark with a tick)

Programmes ( ) or

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Overheads ...( )

All supplier information will be treated strictly confidential.

ALL SUPPLIER INFORMATION WILL BE TREATED STRICTLYCONFIDENTIAL.

NOTE:

a) The information required is mandatory.b) IDT reserves the right to conduct audits and investigations on any

applicant or information supplied in this questionnaire.c) Submit with your application the following documents:

1. An original cancelled cheque or stamped letter from the bank, verifyingthe banking details.

2. Copy of Company Registration documents.3. Certified Copy of ID documents of Directors/Owners/Members/

Shareholders.4. Valid VAT certificate (where applicable).

5. Valid Tax Clearance Certificate (original).6. Copy of registration certificate pertaining to your relevant industry.7. Companies claiming Black Economic Empowerment as per IDTs

definition (see below) to submit copies of the following:

Close Corporations to attach an Association Agreement(Pty) Ltds to attach Shareholders Agreement, Memorandum of Association aswell as share certificates

The above documents to stipulate management responsibilities, profitsharing, liabilities/responsibilities, management contribution, protection incase of death etc.

Letter from the Bank stating all signatories8. Copy of COIDA (Compensation for Occupational Injuries and Diseases)

registration certificate e.g. Letter of Good Standing.

BLACK ENTERPRISES

The following is a guide on how Independent Development Trust definesBlack Enterprise Companies:

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Definition: Black means South African citizens who are Black, Indian orColoured persons and EXCLUDES individuals belonging to such communitiesfrom any other country.

Black Women-owned Enterprises (BWO):

At least 50% of the voting shares or interests are held and controlled byBlack Women, and

Black Women have contributed at least 50% of the required capital, and

Black Women in the enterprise have not been given voting shares orinterest just to capture or retain contracts, and

Black Women participate in the day to day management and decisionmaking of the enterprise. They necessarily have the aptitude andpotential to understand all issues involved in the running of theenterprise including knowledge of the product and market within whichtheir enterprise operates.In a joint venture, skill must be transferable to the Black Womenentrepreneur, which means that the Black Women entrepreneur musthave the required educational level and/or aptitude.

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SECTION A

A1. BUSINESS INFORMATION

Title (Prof./ Dr / Mr / Mrs / Ms/ ) and Surname:____________________________________________(if sole proprietor)

Trading as name ofbusiness:_________________________________________________________

(Contracts/order will be placed on this name and invoices must reflect it)

Previous name of the business (if applicable)______________________________________________

Physical address of business:Building / complex name:

__________________________________________________________

Street name and number:___________________________________________________________

Suburb: _________________________________City:______________________________________

Code: __________________________________Country:____________________________________

Postal address of business: (This is the address to which an Invitation torender sevices and orders/contracts must be sent to)

P O Box / Private Bag:______________________City/Town:________________________Code:_____

Telephone numbers of business: Code: ______ Number:_______________________

Accounts department (Tel no) Code_______ Number:________________________

Contact person fax number: Code: _______Number_________________________(Will be used by IDT for electronic faxing of Request for Services,Contracts and Purchase Orders)

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Business e-mail:____________________________________________________________________

Your own business contact person/marketing representative name andtelephone number:

__________________________________________________________________________________

Business registration number (if applicable)

_______________________________________________(In case of sole proprietor, please furnish identity number plus certifiedcopy of identity documents)

Tax number of business: (if applicable)

_________________________________________________

VAT Registration number: (if applicable)_________________________________________________

A2. BANK INFORMATION:

Please attach an original cancelled cheque or an original bank verification

letter.

Bank: ___________________________________ Branch code:

_______________________

Branch Location:

_____________________________________________________________

Account Holder:

_____________________________________________________________

Bank Account number: __________________________ Account type:

__________________

All payments will be made electronically directly to your bank

account.

Kindly note that it will be your responsibility to inform the IDT, in writing,

of any changes in your banking details.

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(Kindly ensure that all the sections below are fully furnished)

SECTION B:EMPOWERMENT

1. EMPLOYMENT EQUITY

B2.PERCENTAGE OF TOTAL SHARES OWNED BY EACH OF THE FOLLOWING

GROUPS (Attach shareholders Certificate)

% Black % Asian % Coloured % White

% % % %

% Black Female % Asian Female % Coloured Female % White Female

% % % %

% Black Disabled % Asian Disabled % Coloured Disabled% WhiteDisabled

% % % %

B1. MANAGEMENT STRUCTURE

(Percentage of management on executive level in each of the following groups)

% Black % Asian % Coloured % White

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B3. LIST OF ALL PARTNERS, PROPRIETORS ANDSHAREHOLDERS.

(Re (Attach shareholders Certificate)

B4.COMPLETE THE FOLLOWING INFORMATION FOR EACH PARTNER,

PROPRIETOR, SHAREHOLDER, DIRECTOR AND OFFICER OF THEFIRM

(eg Chairman, Secretary, Director, etc)

Name RaceGender

M/F

Disabled

Yes/No

% of timedevotedto firm

Home Address

(PLEASE ATTACH THE COMPANYS EMPLOYMENT EQUITY TARGETFOR NEXT FIVE YEARS)

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B5. WHAT IS THE FIRMS AVERAGE ANNUAL TURNOVER (EXCLUDING VAT)?

R. _____________

B6.

IDENTIFY BY NAME, RACE, GENDER, DISABLILTY AND LENGTH OF SERVICE,THOSE INDIVIDUALS IN THE FIRM (INCLUDING OWNERS AND NON-OWNERS) RESPONSIBLE FOR DAY-TO-DAY MANAGEMENT ANDBUSINESS DECISIONS

Activity Name RaceGender

M/F

Disabled

Yes/No

Lengthof

Service(Years)

Financial Decisions

Cheque Signing

Acquisition of LinesCredit

Sureties

Major Purchase orAcquisitions

Signing Contracts

Management Decisions

Costing

Marketing and SalesOperations

Hiring and firing ofManagementPersonnel

Supervision ofOfficePersonnel

Supervision ofField /ProductionActivities 8


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B7. TOTAL NUMBER OF EMPLOYEES?

Full time

Part time

B8. LOCALITY

PLEASE INDICATE WITH (X) AREAS WHERE YOUR BUSINESS CURRENTLYOPERATES/ AREAS OF REPRESENTATION:

Region Description HO Branch Rep

EC Eastern Cape

FS Free State

GP Gauteng

KZN KwazuluNatal

MP Mpumalanga

NC NorthernCape

NW North West

L Limpopo

WC Western Cape

Kindly indicate: Head Office, Branch Office (s) and where represented only.

Physical address: . Physical address:

...............

... ... ...

Tel no:.. Tel no:

..

Fax no:. Fax no:

.

PO Box/Private Bag... PO Box/Private

Bag...

City:.. City:

..

Code: Code:

Registered Professional name Registered Professional

name..

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Physical address: . Physical address:

..............

.

... ... ...

Tel no:.. Tel no:

..

Fax no:. Fax no:

.

PO Box/Private Bag... PO Box/Private

Bag...

City:.. City:

..

Code: Code:

Registered Professional name Registered Professional

name

Attach list if space provided is inadequate

Is your business:

An agent ______________________________________

Manufacturer___________________________________

Distributor Consultant_____________________________

SECTION C:CAPACITY

1. CAPACITY AND PAST PERFORMANCE

C1.LIST THE THREE LARGEST PROJECTS COMPLETED BY YOUR FIRM IN THE

LAST FOUR YEARS

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Name of ProjectCompleted

Name of ProjectManager

&Telephone no.

Name of Client &Telephone no. Value of Project

C2. LIST THE CURRENT PROJECTS THAT YOUR FIRM IS INVOLVED IN

Name of CurrentProject

Name of ProjectManager &

Telephone no.

Name of Client &Telephone no.

Value of Project

C3. PREVIOUS APPOINTMENTS BY IDT

Project/ProgrammeName

Type of project Contractperiod

ContractValue

Financialyear

IDT ContactPerson & Tel no.

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C4. DID THE FIRM EXIST UNDER A PREVIOUS NAME? YES/ NO

IF YES, WHAT WAS THE NAME:______________________________________________

C4.1 WHO WERE OWNERS/ PARTNERS/ DIRECTORS:

TECHNICAL

C5.IS YOUR BUSINESS A PERMIT HOLDER UNDER THE SABS, MARKSCHEME? (Y / N )

.

IF YES, INDICATE PRODUCT(S) FOR WHICH PERMITS ARE HELD,INCLUDING PERMIT

NUMBERS

QUALITY

C6. HAS YOUR QUALITY MANAGEMENT SYSTEM BEEN ASSESSED &CERTIFIED BY ANY NATIONAL / INTERNATIONALLYRECOGNISED ACCREDITED BODY (Y / N ) IF YES PROVIDE COPYOF CERTIFICATE.

1.TYPE OF BUSINESS

D1. TYPE OF FIRM (Tick applicable box)

Joint Venture

Partnership

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Company

Close Corporation

One Person Business / Sole Trader

Other

D2. Human Resources

1. Briefly state your Affirmative Action (AA) Policy.

D3. Proudly South African

Do you get more than 80% of your material from your Local Area

Geographically : Yes ______________________ No ______________________

PlaceNationally : Yes_______________________ No_______________________

Region

Internationally : Yes_______________________ No_______________________

Country

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SECTION E:

ATTACHMENTS (COMPULSORY)

Please attach certified copies/original of the following documents: Tick

Fully Completed Supplier Questionnaire

Cancelled cheque or an original bank verification letter

ID Documents of owners

Company Registration Documents

D4. SAFETY (Tick applicable box)

1. Does your business have an Occupational Health Policy complying to the Occupational Health

and Safety Act (OHSA) Yes/No

2. Are you registered with Compensation for Occupational for Occupational Injuries and DiseasesAct (COIDA) Yes/No

COIDA registration number_________________________________

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Shareholders agreements / certificates for companies

claiming Black Economic Empowerment

VAT certificate (if a VAT vendor)

Valid Tax clearance certificate

JVS Agreement (if a joint venture)

SWORN STATEMENT

I/we, the undersigned, who warrant that I/we am/are duly, authorised to do so,on behalf of the enterprise, certify that:

a) The information furnished is true and correct.

b) If misrepresentation to gain any benefit is established, IndependentDevelopment Trust may in addition to any other remedy it may have

disqualify the applicant;

restrict the applicant, its shareholders and directors fromobtaining business from Independent Development Trust for aperiod not exceeding 5 years;

in the event that a contract has been concluded, recover fromthe contractor all costs, losses or damages incurred or sustained

as a result of the award of the contract; cancel the contract and claim any damages suffered by having

to make less favourable arrangements after such cancellation;and

c) Independent Development Trust is hereby empowered to take suchsteps as it may require to verify information submitted, including, butnot limited to, the use of independent auditors or other experts.

d) If there are any changes to the information supplied on this form, I/Wewill inform Independent Development Trusts Supply ChainManagement Unit immediately.

(INCOMPLETE SUBMISSIONS WILL NOT BE PROCESSED. THISINCLUDES THE SUPPORTING DOCUMENTATION AS STIPULATED)

Name of Enterprise:.

Signature of Enterprise Representative:

.

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Address..Telephone no: ....Date:

--------------------------------------------------------------------- ---------------------

For and on behalf of the company Date

--------------------------------------------------------------------------------

Capacity of signatory (Position held in Company)

FOR IDT USE ONLY:

1. Supplier Approval:

Procurement Department: ______________ Date __________

Senior Supply Chain: ______________________ Date______________

Information captured on IDT supplier database:

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by (name)_____________________________ Date _____________

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Questionnaire for Supplies - Goods (2)

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