SUPPLIER DATABASE REGISTRATION FORM 2016 -...

SUPPLIER DATABASE REGISTRATION FORM – 2016

Section 1: Company Details and General Information

Name of Company: Trading Name(if applicable):

Street Address: Postal Address:

City: Code:

Email Address of Contact Person:

1.

2.

Telephone Number:

WWW Address: Cellphone Number:

Contact Name and Title: Alternative Contact Person:

Parent Company (Full Legal Name):

Subsidiaries, Associates & Overseas Representative(s) - (attach a List if necessary)

Type of Business (Mark one only):

Corporate/Limited: Sole Trader: Trust: Other (specify):

Nature of Business:

Manufacturer: Authorised

Agent:

Trader: Consultant: Other (specify)

Year Established: Company Registration No. (please attach company

reg. documents):

Income Tax Number (please attach valid Tax

Clearance Certificate):

VAT No:

B-BBEE Status Level (please attach valid B-BBEE

Certificate):

EXEMPT ENTERPRISE (YES/NO)(please attach

certified affidavit/certificate):

Core Commodity:

Section 2: Financial Information

Annual Turnover for the past 3 years (please provide most recent annual/audited financial report):

Year:

ZAR:

Year:

ZAR:

Year:

ZAR:

Bank Details (please provide proof in the form of an original letter from the bank/Cancelled Cheque):

Bank Name: Bank Account No.:

Authorised Contact Person in Accounts:

Name: Designation:

Section 3: Technical Capability and Information on Goods/ Services Offered

Professional/Trade Membership (e.g. PrEng) (please provide copy/ies of latest certification):

Quality Assurance Certification (e.g. ISO 9000 or Equivalent) (please provide copy/ies of latest certification):

Safety, Health & Environment (SHE) (please provide copy of latest policy in place):

For goods only, do those offered for supply conform to SABS/International quality standards? (YES/NO):

List Below your core goods/services offered:

Description National/International Quality Standard to which item conforms

Disclaimer: By completing this form does not automatically mean you will be added to our supplier database. There will be a review and an evaluation process that must take place first.

TERMS AND CONDITIONS:

1. The Gautrain Management Agency (GMA) reserves the right to accept or reject any application

without being obliged to give any reasons in this respect.

2. Registration onto the (GMA) supplier database does not guarantee business opportunities.

3. The forms must be completed in full and signed off by the duly authorized signatories.

4. Full signatures are required when alterations are made in this document.

5. If the information required is not applicable to your business, clearly insert the symbol “N/A” in the

appropriate space.

6. Mark the appropriate box with a “tick”/”X” where it is applicable to your business.

7. If the space is left blank, the form will be regarded as incomplete and may lead to automatic

disqualification.

8. No faxed or emailed applications will be accepted. Only original and signed copies of application will

be accepted.

9. Suppliers may not alter the application form in any way.

10. A company profile must accompany the registration form but will not be accepted as a substitute for

this application form.

11. Applicants will be contacted via email and must therefore submit alternative email addresses.

12. Suppliers registered onto the Supplier database should ensure that they furnish the GMA with any

change to the status of the information initially provided as and when the information changes.

13. It is the duty of the supplier to ensure the GMA is always in possession of an original valid tax

clearance certificate, B-BBEE certificate and valid bank details.

14. Suppliers must attach original/certified relevant industry accreditation where applicable.

15. Suppliers that have been registered onto the database will be continuously monitored for their

performance on work awarded to them.

16. The continuous monitoring process will form the basis of evaluating supplier’s performance, which

will have impact on future procurement opportunities with the GMA.

17. The completed form and all required supporting documentation must be placed in an enveloped and

hand delivered/ dropped the tender box at the following address:

Physical Address of Tender Box: 44 Grand Central Boulevard, Midrand (Off R101 Old

Johannesburg Road)

Hours of access to Tender Box: Between 07:00 and 17:00 (Weekdays only)

Information to be marked on

envelope containing application:

Gautrain Management Agency

SCM Unit

SUPPLIER DATABASE REGISTRATION - 2016

Name of Supplier:

18. Please mark the back of the envelope with Sender (Business Name), Contact Person and

Telephone Number.

19. Application forms received after closing date will not be considered.

20. A list (not exhaustive) of categories of goods/services that a supplier wishes to register

for as a supplier is attached as annexure A.

DECLARATION:

I, the undersigned, (NAME IN FULL) ______________________________________________________certify

that the information furnished is true and correct.

SIGNATURE:______________________________________________________________

DATE:_____________________________

SBD 4

DECLARATION OF INTEREST

1. Any legal person, including persons employed by the state¹, or persons having a kinship with persons

employed by the state, including a blood relationship, may make an offer or offers in terms of this invitation to

bid (includes an advertised competitive bid, a limited bid, a proposal or written price quotation). In view of

possible allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons employed

by the state, or to persons connected with or related to them, it is required that the bidder or his/her

authorised representative declare his/her position in relation to the evaluating/adjudicating authority where-

- the bidder is employed by the state; and/or

- the legal person on whose behalf the bidding document is signed, has a relationship

with persons/a person who are/is involved in the evaluation and or adjudication of the bid(s), or where it is

known that such a relationship exists between the person or persons for or on whose behalf, the declarant acts

and persons who are involved with the evaluation and or adjudication of the bid.

2. In order to give effect to the above, the following questionnaire must be completed and submitted

with the bid.

2.1 Full Name of bidder or his or her representative: ……………………………….……………………………….

2.2 Identity Number:……………………………………………………………………………………………………………………………

2.3 Position occupied in the Company (director, trustee, shareholder, member):……………………….……….

2.4 Registration number of company, enterprise, close corporation, partnership agreement or

trust:…………......................………………………………………………….................................

2.5 Tax Reference Number: …………………………………………………………………………………….

2.6 VAT Registration Number: ………………………………………………………………………………....

2.6.1 The names of all directors / trustees / shareholders / members, their individual identity numbers, tax

reference numbers and, if applicable, employee / PERSAL numbers must be indicated in paragraph 3 below.

2.7 Are you or any person connected with the bidder YES/NO

Are you or any person connected with the bidder presently employed by the state? YES/NO

2.7.1 If so, furnish the following particulars:

Name of person / director / trustee / shareholder/ member: ……....……………………………………

Name of state institution at which you or the person

connected to the bidder is employed: ……………………………………………………

Position occupied in the state institution: ………………………………………………………………………..

Any other particulars:

………………………………………………………………

………………………………………………………………

………………………………………………………………

2.7.2 If you are presently employed by the state, did you obtain the appropriate authority to undertake

remunerative work outside employment in the public sector? YES/NO

2.7.1.1 If yes, did you attach proof of such authority to the bid document? YES/NO

(Note: Failure to submit proof of such authority, where applicable, may result in the disqualification of the bid.

2.7.1.2 If no, furnish reasons for non-submission of such proof:

…………………………………………………………………….

…………………………………………………………………….

…………………………………………………………………….

2.8 Did you or your spouse, or any of the company’s directors / trustees / shareholders / members

or their spouses conduct business with the state in the previous 12 months YES/NO

2.8.1 If so, furnish particulars:

…………………………………………………………………..

…………………………………………………………………..

…………………………………………………………………...

2.9 Do you, or any person connected with the bidder, have YES/NO

any relationship (family, friend, other) with a person

employed by the state and who may be involved with

the evaluation and or adjudication of this bid?

2.9.1 If so, furnish particulars.

……………………………………………………………...

…………………………………………………………..….

………………………………………………………………

2.10 Are you, or any person connected with the bidder, aware of any relationship (family, friend, other)

between any other bidder and any person employed by the state who may be involved with the evaluation and

or adjudication of this bid? YES/NO

2.10.1 If so, furnish particulars.

………………………………………………………………

………………………………………………………………

………………………………………………………………

2.11 Do you or any of the directors / trustees / shareholders / members YES/NO

of the company have any interest in any other related companies

whether or not they are bidding for this contract?

2.11.1 If so, furnish particulars:

…………………………………………………………………………….

…………………………………………………………………………….

…………………………………………………………………………….

3 Full details of director /trustees/members/shareholders.

Full Name Identity Number Personal Income Tax

Reference Number

State Employee

Number / Persal

Number

4. DECLARATION

I, THE UNDERSIGNED (NAME)………………………………………………………………………

CERTIFY THAT THE INFORMATION FURNISHED IN PARAGRAPHS 2 AND 3 ABOVE IS CORRECT.

I ACCEPT THAT THE STATE MAY REJECT THE BID OR ACT AGAINST ME SHOULD THIS DECLARATION

PROVE TO BE FALSE.

NAME OF BIDDER

IDENTITY NUMBER

POSITION

SIGNATURE OF AUTHORISED SIGNATORY

CHECKLIST Documents to be submitted by an applicant for eligibility checking during the registration process. If any of the

required documents are not submitted as prescribed may invalidate the application. The applicant is to indicate

that the documentation is complete and included in the application document by completing the table below.

ITEM DESCRIPTION YES NO

1. Is your supplier database registration form completed in full and

signed?

2. Have you completed SBD 4 (Declaration of Interest) in full and

signed?

3. Have you submitted the following documents:

4. Original valid tax clearance certificate

5. Original valid B-BBEE certificate

6. Original bank details – either a cancelled cheque or letter from the

bank

7. Company profile

8. Most recent annual/audited financial report

9. Valid original/ certified copy of proof of professional/trade

membership

10. Valid original/certified copy of proof of quality assurance

11. Certified copies of Original of Company Registration Documentation

NB: Certification stamp must be original and no more than 3 months

old as at date of closing of tender

1. certificate of registration,

2. change of name certificate (if applicable)

3. register of directors, and most current registered business

address

(Company Registration: CM1 and CK1, Change of Name

Certificate:CM9, Latest Registered address: CM22,Most current

register of directors CM29 and CK2)

12. Original certified copies of shareholders/directors/owners/members

identity documents

13. SHE (Safety , Health and Environment)

Tick to indicate that the information is included

ANNEXURE A LIST OF COMMODITIES

A commodity is a category of goods/services that business wishes to register for as a supplier. The list is for your

information only. Please do not submit this list with your application form.

Advertising (Placement of Advertisements

Electronic Media

Outdoor Media

Print Media

Archiving & Related Services

Archiving & Related Services

Assets & Goods

Electronic Equipment (projectors, Cameras, etc.)

Kitchen Electrical Appliances (e.g. Microwave, Urn, Electric Kettle, Coffee Machines)

Office Equipment

Office Furniture (Indicate % local content in production of all items of furniture that you supply)

Assets Services

Audio & Video Systems (Maintenance & Support)

Panel Beating / Spray Painting

Refrigeration Equipment Repairs

Repair of Office Furniture

Construction Related

Paving

Other

Corporate Clothing & Gifts

Corporate Clothing, Promotional Items & Gifts(indicate % local content in production of all textile items

that you supply)

Framing of wall posters

Document Services

Courier Services (incl. Postal Services)

Content Development/Editing

Copy Editing

Graphic Design

Transcription

HR Related Services

Business Management

Change Management Consultants

Coaching Consultants

Consultants

Employment Equity Strategy Development

Executive Search Consultants

HR Management Consultants

HR Strategic Planning & Development

HR Strategic Planning Facilitation

Knowledge Management Solution

Organisational Dynamics Consultants

Organisational Transformation

Performance Management

Personal Development

Recruitment Agencies

Remuneration & Salary Structuring/benchmarking Consultants

Skills Analysis & Development Consultants

Staff Wellness Services

Team Building Organisers

Transcription Services

Workshop Facilitators

IT Related Services

Boardroom Solutions

Cloud Services

General IT Software and Hardware

Infrastructure Specialist for: Network Infrastructure Air-Conditioning Access Control CCTV Server Rooms

IT Hardware & Network Maintenance & Support

IT Network Cabling

IT Professional Services (Consulting)

IT Security Services

IT Software (Operating & Other)

Laptop & Desktop Hardware and Software

Mobile Applications and Solutions

Printers and Printer Consumables

Security Solution Systems

Server Hardware and Software

Specialist IT Services, Architecture, Security, etc.

Telephony and Collaboration Systems

Office Management Goods

Carpets / Carpeting Installation

Fresh Milk

Design and Making of Uniforms

Dry Groceries (Wholesale and Retail)

Household Cleaning Materials

Shelving (Steel & Wood)

Stationery

Other Groceries

Office Management Services

Catering

Cleaning (General and Specialised, incl. Carpet Cleaning)

Fire Detection, Prevention and Security Systems

First Aid Supplies / Equipment / Kits (OHASA)

Pest Control / Fumigation

General Handy Man

Pot Plant Supply & Servicing

Sanitation

Supply of Newspapers, Journals, etc.

Maintenance & Related Services

Air Conditioning Specialist

Minor Building Contractors

Carpet / Upholstery Cleaning

Construction Maintenance Services

Electrical (Globes, Plugs, Wire, etc.) Maintenance

Furniture Repairs & Maintenance

Furniture Removals

Plumbing (Toilet Seats, Washers, Taps, etc.)

Recycling Services

Marketing & Communications Services

Corporate Communications

Corporate Promotional Gifts

Digital/Website/Online Services

Geographic Information Systems (Apps & Maps)

Social Media Research

Design & Printing

Photocopying

Aerial Photography

Filming & Videography

Communications and Marketing Research

Data Analysis

Events Management

Communications & Stakeholder Management

Media Monitoring Research

Media Management

Transport for Events

Exhibition Stands

Brand Management

Public Relations & Consulting Services

Stakeholder Perception Survey Services

Printing & Related

Copying Services

Printing, Layout & Design (e.g. Annual Report, Folders, Business Cards, Diaries, brochures, etc.)

Professional Services: Other

Accounting & Auditing Services

Architects

Asset Management Consultants

Business Advisory Consultants

Business Analysis & Design Consultants

Business Management Consultants

Business Process Re-Engineering Consultants

Business Solutions Consultants

Corporate Compliance Services

Corporate Governance Services

Engineers

Environmental auditing, consulting and specialist reporting services

Financial & System Integration Consultants

Financial Administration Consultants

Financial Planning Consultants

Financial Systems Consultants

Forensic Investigations

Geographic Information Systems

Governance Consultants

Health & Safety Programmes (CPR)

Health, Safety and Environmental legal auditing services

Industrial Theater

Internal Audit and Consulting

Procurement Advisory Services

Project Management Consultants

Public Relations & Consulting Services

Quantity Surveyors

Risk Management Consultants

Security (Physical/digital)

Strategic Planning & Development Consultants

Strategic Planning Facilitation

Travel, Accommodation & Related

Accommodation

Car hire

Transport Services (Buses, Shuttles, Other

Travel Agencies

Venue Finders

Rental

Crockery & Cutlery

Décor

Office Equipment

Screens

Security

Locks & Keys

Safes

Vehicle Tracking Systems

Training (SETA Accredited etc.)

Business Process Mapping & Modelling Training

Business Writing Skills

Career Management

Change Management Training

Communication Skills

Conflict Management Training

Corporate Secretariat Training

Diversity Training

Document Management Training

Employee Wellness Programmes

Employment Equity Training

Etiquette Training

Facilities Management Training

Financial Management Training

Governance Training

Health, Safety and Environmental training services

Human Resources Development/Management Training

Internal Audit Training

Interpersonal Skill Training

IT Development Training

Labour Law Training

Leadership/ Management Development Programmes

MS Office Training

Negotiation Skills

Occupational Health & Safety Training (First Aid Training etc.)

Organisational Development Training

Performance Management Training

Personal Assistant Training

Policies & Procedures Development Training

Prevention & Detection of Procurement & Contract Fraud Training

Project Management Training

Report Writing Skills

Skills Development Facilitator Training

Strategic Planning Training

Supervisory Development Training

Time Management Training

Women in Leadership Training

Other Commodities Not Listed

(PLEASE ENSURE THE COMODITIES YOU LIST UNDER THIS SECTION ARE NOT COVERED ABOVE)

SUPPLIER DATABASE REGISTRATION FORM 2016 -...

Documents

Transcript of SUPPLIER DATABASE REGISTRATION FORM 2016 -...