J/common – Nelson Mandela Bay Municipality Supplier Database Registration form – 03 July 2013

Enquiries: Tel 041-5063274 / 041-5063266 email: scmdatabase@mandelametro.gov.za

NELSON MANDELA BAY METROPOLITAN MUNICIPALITY SUPPLIER DATABASE

(NMBMMSD) REGISTRATION APPLICATION FORM

It is imperative that prospective providers read the application form

carefully and complete it in full.

Database application forms may be obtained from:

Nelson Mandela Bay

Municipality

Supply Chain

Management Compliance

Office

Corner Harrower Road &

Buxton Street

Kensington

Nelson Mandela Bay

Municipality

Budget and Treasury Customer

Care Office,

Town Hall

Market Street

Uitenhage

www.mandelametro.gov.za

Tel: 0415063274

Tel: 0415063266

Fax: 0865144305

scmdatabase@mandelametro.gov.za

Completed forms may be delivered: (Only valid original Tax Clearance Certificate is acceptable)

By Hand Post

Database Administrator

SCM Compliance

Cnr Buxton street & Harrower Road

Nelson Mandela Bay Municipality

Supply Chain Management: Compliance

PO Box 3188

North End

Port Elizabeth

6001

Queries may be directed to the above listed contact details.

NB:

Attach a certified ID copy of the page 9 signatory

Messenger’s ID is required on submission of the

form

AND

Certified Documents must not be older than 3

Months

http://www.mandelametro.gov.za/mailto:scmdatabase@mandelametro.gov.za

J/common – Nelson Mandela Bay Municipality Supplier Database Registration form – 03 July 2013

Enquiries: Tel 041-5063274 / 041-5063266 email: scmdatabase@mandelametro.gov.za

In addition to a fully completed form, the following documents must be provided where applicable

Nelson Mandela Bay Supplier Database

D O C U M E N T S R E Q U I R E D

Sole Proprietor

Co-operatives Close Corporations and Private Companies

Partnerships Public Company

Business Trust

Non Profit Organisations

(NPO)

Where to get documents

Address Telephone

Company Registration document

Letter of Authority

The DTI Campus Block F (Entfutfukweni)

012 3108789

77 Meintjies Street DTI Call Centre

Sunnyside, Pretoria 0861843384

The DTI Campus Block F (Entfutfukweni) 77 Meintjies Street Customer Sunnyside, Pretoria 0861843384

Section 12 Signatory

Section 12 Signatory &

Section 12

12 Signatory &

Section 12 Signatory &

Section 12

12 Signatory &

Section 12 Signatory &

Section 12 Signatory &

Original Proof of Banking Stamped Bank Statement OR Orig cancelled

cheque AND Bank Stamp and signature on (Pg 5).

Stamped Bank

Bank Statement OR

OR Orig.cancelled cheque AND Bank Stamp and signature on (Pg 5).

Stamped Bank

Bank Statement OR

OR Orig.cancelled cheque AND Bank Stamp and signature

signature on (Pg 5).

Stamped Bank

Bank Statement OR

OR Orig.cancelled cheque AND Bank Stamp and signature on (Pg 5).

Stamped Bank

Bank Statement OR

OR Orig.cancelled cheque AND Bank Stamp and signature

signature on (Pg 5).

Stamped Bank Statement OR Orig.cancelled cheque AND Bank Stamp and signature on (Pg 5).

Stamped Bank Statement OR Orig.cancelled cheque AND Bank Stamp and signature on (Pg 5).

Branch of bank where account is held

An Original valid Tax Clearance Certificate

For the owner or the business

For the co- operative

For the company / cc

cc

For each individual shareholder

For the company

y

For the trust For the NPO Receiver of Revenue (SARS)

SANLAM BUILBING CHAPEL ST Port Elizabeth

041 –505 7500

BBBEE Rating Certificate ORIGINALLY CERTIFIED COPY

BBBEE Rating Certifcate or EME Certificate if annual turnover is

J/common – Nelson Mandela Bay Municipality Supplier Database Registration form – 03 July 2013

Enquiries: Tel 041-5063274 / 041-5063266 email: scmdatabase@mandelametro.gov.za

NELSON MANDELA BAY METROPOLITAN MUNICIPALITY SUPPLIER DATABASE

(NMBMMSD) APPLICATION FORM

Name of Business

Trading Name

CTIPlPlease Note: Proof documents for all of the above are required to ensure successful registration on the WCSD. In the event of a document not being required please tick the N or N/A box. Please refer to Page 2 for detailed information with regard to documents required.

Please tick in box: Y N N/A

Company Registration Document (Certified)

Proof of Ownership / Shareholder certificate (Certified)

Originally Certified BBBEE Rating Certificate

Identity Document for Certificate of Correctness

Signatory (Certified)

Co-Operatives – Registration Certificate

Proof of Banking Document

UIF Document This MUST reflect on the Tax Clearance Certificate if applicable

Compensation Fund: Letter of Good Standing

VAT Registration Document This MUST reflect on the Tax Clearance Certificate if applicable

PAYE Document This MUST reflect on the Tax Clearance Certificate if applicable

Billing Clearance Certificate

An Original Valid Tax Clearance Certificate (TCC)

Security Officer’s Board Certificate

Contractors Registration Certificate (Issued by the CIDB)

Disability Documents

Please Note: Proof of documents for the entire above is required to ensure successful registration on the Supplier Database. In the event of a document not being required please tick the N or N/A box. Please refer to Page 2 for detailed information with regard to documents required.

SECTION 1

J/common – Nelson Mandela Bay Municipality Supplier Database Registration form – 03 July 2013

Enquiries: Tel 041-5063274 / 041-5063266 email: scmdatabase@mandelametro.gov.za

1. COMPANY REGISTRATION DOCUMENTS NB. DOCUMENTARY PROOF MUST BE PROVIDED WHERE APPLICABLE (Please mark N/A if not applicable.)

1.1 COMPANY TYPE (NB Documentary Proof of registration must be provided)

BUSINESS TRUST CERTIFIED COPY OF CERTIFICATE OF INCORPORATION (CM 3)

CLOSE CORPORATION CC CERTIFIED COPY OF CERTIFICATE OF INCORPORATION (CM 3)

CO-OPERATIVE CERTIFIED COPY OF REGISTRATION CERTIFICATE

PARTNERSHIP CERTIFIED COPY OF CK 1 DOCUMENT OR CK 2 IF APPLICABLE

PRIVATE COMPANY (PTY) LTD N/A

PUBLIC COMPANY LTD COPY OF PARTNERSHIP AGREEMENT

SOLE PROPRIETOR CERTIFIED COPY OF REGISTRATION DOCUMENT

NON PROFIT ORGINISATION

OTHER ______________________________ CERTIFIED COPY OF REGISTRATION DOCUMENT

Company, CK Number

Not applicable to all companies, please specify if N/A Y N N A

Have you attached a Certified copy of your Company Registration document or other applicable documentation if N/A? (see attached table)

1.2 PROOF OF SHAREHOLDING DOCUMENTS

CERTIFIED COPIES of Shareholders certificates or CK members share allocation documents must be supplied

Not applicable to all companies, please specify if N/A Y N NA

Have you attached certified copies of shareholder documents or other applicable documentation if N/A? (see attached table)

1.3 BILLING CLEARANCE CERTIFICATE

Y

Have you attached your Billing Clearance Certificate document?

1.4 PROOF OF BANKING DOCUMENTS

Current bank statement and copy of cancelled cheque Y

Have you attached proof of banking document?

1.5 UNEMPLOYMENT INSURANCE FUND DOCUMENTS

Unemployment Insurance fund No.

Y

N

A

Have you attached your UIF document? (All sole proprietors to register business with the Dept of Labour)

1.6 COMPENSATION FOR OCCUPATIONAL INJURIES & DISEASES FUND DOCUMENT

Compensation Fund Registration No.

Y

N

A

Have you attached your Letter of Good Standing document?

1.7 VAT REGISTRATION DOCUMENT

VAT Registration No.

Y N

A

Have you attached proof of your VAT registration document if VAT no. not indicated on Tax Clearance Certificate?

1.8 P.A.Y.E DOCUMENT

P.A.Y.E. No.

Y

N

A

Have you attached proof of your P.A.Y.E document if PAYE no. not indicated on Tax Clearance Certificate?

1.9 INCOME TAX REGISTRATION NUMBER

Income Tax Registration number

1.10 TAX CLEARANCE CERTIFICATE

An original valid Tax Clearance Certificate must be supplied Y

As this is only valid for a twelve-month period from date of issue, an original valid Tax Clearance Certificate is to be submitted upon or before expiry of the one submitted to avoid suspension on the WCSD. Have you attached an original valid Tax Clearance Certificate?

1.11 SECURITY OFFICERS BOARD REGISTRATION NO (M ANDATORY, IF APPLICABLE)

Security officers board registration No.

Applicable to security industry only, please specify if N/A Y

N

A

Have you attached your Security Officers Board Registration document?

1.12 CONSTRUCTION INDUSTRY DEVELOPMENT BOARD (CIDB) REGISTRATION (MANDATORY, IF APPLICABLE)

CIDB Contractors registration No.

CIDB Class of work

Y N

A

Have you attached your CIDB Proof of registration?

1.13 DISABILITY DOCUMENTS

SECTION 2

J/common – Nelson Mandela Bay Municipality Supplier Database Registration form – 03 July 2013

Enquiries: Tel 041-5063274 / 041-5063266 email: scmdatabase@mandelametro.gov.za

Y

N

A

Have you attached your proof of disability document?

1.14 CO-OPERATIVES

T = Tertiary, S= Secondary or P = Primary T S P

Indicate which Co-operative level your company is registered under?

Y N

Have you attached your proof of registration?

J/common – Nelson Mandela Bay Municipality Supplier Database Registration form – 03 July 2013

Enquiries: Tel 041-5063274 / 041-5063266 email: scmdatabase@mandelametro.gov.za

2. BUSINESS PARTICULARS

2.1 Name of Business

2.1.1 Business Trading Name

2.1.2 Head Office

Postal address

City Code

Province

2.1.3 Head Office

Physical address

City Code

Province

2.1.4 Head Office Telephone No.

2.1.5 Head Office Fax No.

2.1.6 E-mail Address

2.1.7 Contact Person for correspondence as per 2.11

Title First Name

Surname

2.1.8 Cell No.

2.1.9 Correspondence Method – (Email address – mandatory requirement)

Email Address

Fax Number

Ward Number (Applicable to Residents of Nelson Mandela Bay only)

SECTION 3

J/common – Nelson Mandela Bay Municipality Supplier Database Registration form – 03 July 2013

Enquiries: Tel 041-5063274 / 041-5063266 email: scmdatabase@mandelametro.gov.za

3. BRANCHES, SALES AND ACCOUNTS DEPARTMENTS

3.1 Sales Department

Contact Name

Cell No

Email Address

Telephone Fax

3.2 Accounts Department

Contact Name

Cell No

Email Address

Telephone Fax

3.3 Branches

Y N

Do you have any other branches in this region?

If yes, kindly complete 3.3 below

Multiple copies of this page may be submitted if required.

Name / Area

Physical Address

City Code

Province

Telephone Fax

Name / Area

Physical Address

City Code

Province

Telephone Fax

Name / Area

Physical Address

City Code

Province

Telephone Fax

Name / Area

Physical Address

City Code

Province

Telephone Fax

SECTION 4

J/common – Nelson Mandela Bay Municipality Supplier Database Registration form – 03 July 2013

Enquiries: Tel 041-5063274 / 041-5063266 email: scmdatabase@mandelametro.gov.za

4.1 CORE BUSINESS OPERATION ( M A N D A T O R Y F I E L D ) * *

(Mark with X in applicable fields)

Prime Contractor Sub-Contractor (less than 25 % generated turnover as prime contractor)

Labour-only Contractor

Supplier Manufacturer Legal Service Provider*

Professional Services BUILT Environment*

Education, Training and Development Service Provider (ETD)*

Other**

*NB – All Professional Service Providers in the Built Environment, all ETD Service Providers and all Legal Entities, must contact our offices to request the mandatory additional registration pages applicable to this specific core business sector.

**Other, please specify_____________________________________________________________________________________

4.2 ANNUAL AVERAGE TURNOVER

Indicate annual average turnover excluding Value Added Tax during the past three years:

4.3 ANNUAL AVERAGE TURNOVER*

Indicate annual average turnover excluding Value Added Tax during the past three years:

1_____ R 2_____ R 3_____ R

5. FINANCIAL DETAILS (BANKING)

Banking institution name

Branch Name

Town / City

Branch Code

Banking account number

Account holders name

Account Type

NB. MANDATORY REQUIREMENT

The template below must be completed, signed and stamped by a Bank official to validate the bank details.

DATE STAMP OF BANK (not older than 3 months) FOR COMPLETION BY BANK OFFICIAL

Bank Official’s Detail

Name

Staff Number

Signature

Branch Tel Nr

Supplier’s Detail

Account nr

Branch Code

SECTION 5

6 . BUSINESS INFORMATION ( M A N D A T O R Y F I E L D ) * *

The following table must be completed in order to establish whether a business can be classified as an SMME in terms of the National Small Business Amendment Bill pertaining to the

National Small Business Act 102 of 1996. Indicate the sector by ticking the appropriate block in column 1 and then tick the corresponding information blocks in columns 2, 3 and 4.

COLUMN 1 COLUMN 2 COLUMN 3 COLUMN 4

Sector or sub-sectors in accordance with the Standard Industrial Council

Total full time equivalent of paid employees

TICK WHERE APPLICABLE

Total annual turnover

TICK WHERE APPLICABLE

Total gross asset value (fixed property

excluded). TICK WHERE APPLICABLE

Agriculture MORE THAN 100 Medium MORE THAN R 5m MORE THAN R 5m

LESS THAN 100 LESS THAN R 5m LESS THAN R 5m

Mining and Quarrying MORE THAN 200 MORE THAN R 39m MORE THAN R 23m

LESS THAN 200 LESS THAN R 39m LESS THAN R 23m

Manufacturing MORE THAN 200 MORE THAN R 51m MORE THAN R 19m

LESS THAN 200 LESS THAN R 51m LESS THAN R 19m

Electricity, Gas and Water MORE THAN 200 MORE THAN R 51m MORE THAN R 19m

LESS THAN 200 LESS THAN R 51m LESS THAN R 19m

Construction MORE THAN 200 MORE THAN R 26m MORE THAN R 5m

LESS THAN 200 LESS THAN R 26m LESS THAN R 5m

Retail, Motor Trade and Repair Services MORE THAN 100 MORE THAN R 39m MORE THAN R 6m

LESS THAN 100 LESS THAN R 39m LESS THAN R 6m

Wholesale Trade, Commercial Agents & Allied Services

MORE THAN 100 MORE THAN R 64m MORE THAN R 10m

LESS THAN 100 LESS THAN R 64m LESS THAN R 10m

Catering, accommodation & other Trade MORE THAN 100 MORE THAN R 13m MORE THAN R 3m

LESS THAN 100 LESS THAN R 13m LESS THAN R 3m

Transport, Storage and Communications MORE THAN 100 MORE THAN R 26m MORE THAN R 6m

LESS THAN 100 LESS THAN R 26m LESS THAN R 6m

Finance and Business Services MORE THAN 100 MORE THAN R 26m MORE THAN R 5m

LESS THAN 100 LESS THAN R 26m LESS THAN R 5m

Community, Social & Personal Services MORE THAN 100 MORE THAN R 13m MORE THAN R 6m

LESS THAN 100 LESS THAN R 13m LESS THAN R 6m

SECTION 6

7.1 OWNERS AND SHAREHOLDERS

7.1 Attach a list all persons who are shareholders/owners and managers in the business

NB Proof of disability provided by a recognised institution in the case of handicapped persons must be supplied.

NB: Declaration form must be completed in full (Section 13).

NB CERTIFIED COPY OF SHAREHOLDER CERTIFICATES OR PROOF OF OWNERSHIP/PARTNERSHIP MUST BE SUPPLIED (Multiple copies of this page may be submitted if required.)

7.2 PARTICULARS OF EMPLOYEES

State the total number of permanent and temporary staff employed.

MALE FEMALE

Permanent Temporary Permanent Temporary

BLACK

COLOURED

INDIAN

WHITE

OTHER

DISABLED

7.3 BBBEE STATUS

CERTIFIED COPY of BBBEE Rating Certificate. Please select the relevant status below and attach the relevant document:

Valid BEE Certificate Status Level Of Contribution

EME Certificate

Status Level Of Contribution

Letter / proof from

agency that application

has been submitted to

BEE verification agency

(no preference points

allocated)

Letter from agency that

the supplier is in

process of BEE

verification (no

preference points

allocated)

FOR OFFICIAL PURPOSES ONLY BEE Certificate EME LETTER Accounting officer/Auditors details Accounting Officers practice number Physical location of the entity Registration number of the entity Date of issue Expiry Date Status Level of contribution Total black shareholding Total black female www.sanas.co.za/af-directory/bbbee list.php.

SECTION 7

http://www.sanas.co.za/af-directory/bbbee%20list.phphttp://www.sanas.co.za/af-directory/bbbee%20list.php

8. PREVIOUS CONTRACT OR TENDERING EXPERIENCE (Mark with X)

Y N

Do you have any previous contract work or tendering experience?

If yes, please complete the table below. List the last 2 contracts awarded to you (the tenderer) or previous experience with other

businesses related to this type of work or supply.

Employer/Department

Contact Person

Contact Number

Estimated Contract Value in Rands R

Year Awarded Year Completed / Still in Progress

Y N

Proof documents attached?

Employer/Department

Contact Person

Contact Number

Estimated Contract Value in Rands R

Year Awarded Year Completed / Still in Progress

Y N

Proof documents attached?

Employer/Department

Contact Person

Contact Number

Estimated Contract Value in Rands R

Year Awarded Year Completed / Still in Progress

Y N

Proof documents attached?

Employer/Department

Contact Person

Contact Number

Estimated Contract Value in Rands R

Year Awarded Year Completed / Still in Progress

Y N

Proof documents attached?

Employer/Department

Contact Person

Contact Number

Estimated Contract Value in Rands R

Year Awarded Year Completed / Still in Progress

Y N

Proof documents attached?

Employer/Department

Contact Person

Contact Number

Estimated Contract Value in Rands R

Year Awarded Year Completed / Still in Progress

Y N

Proof documents attached?

SECTION 8

9. CERTIFICATE OF CORRECTNESS OF INFORMATION SUPPLIED IN THIS DOCUMENT

I/WE, THE UNDERSIGNED, WHO WARRANTS THAT HE/SHE IS DULY AUTHORISED TO DO SO ON BEHALF OF THE

SUPPLIER, CERTIFIES THAT THE INFORMATION SUPPLIED IN TERMS OF THIS DOCUMENT, INCLUDING THE

SUPPORTING DOCUMENTATION, IS CORRECT AND ACCURATE AND ACKNOWLEDGES THAT: -

1. The supplier will be required to furnish documentary proof of the claims if requested to do so.

2. If the information supplied is found to be incorrect then the client may, in addition to any remedies it may have: -

i. Recover from the contractor all costs, losses or damages incurred or sustained by the client as a result of the award of the contract, and/or

ii. Cancel the contract and claim any damages which the client may suffer by having to make less favourable arrangements after such cancellations: and/or

iii. Impose a penalty on the contractor as provided for in the relevant organisation’s regulations.

SIGNED ON THIS _________ DAY OF_________________ 201___ AT_________________________________

__________________________________ ____________________________

(AUTHORISED SIGNATURE) IN HIS /HER CAPACITY AS

__________________________________

(PLEASE PRINT NAME OF AUTHORISED SIGNATURE)

ON BEHALF OF THE (SUPPLIER’S NAME)______________________________________________________

NB - PLEASE PROVIDE A CERTIFIED COPY OF THE IDENTITY DOCUMENT FOR THE SIGNATORY.

NB - Your Tax Clearance Certificate is only valid for a twelve (12) month period from the date of issue. A valid Tax

clearance is required to update your tax status. Please note that: Section 43 of SCM regulations prohibits the award of

tenders to persons whose tax matters are not in order.

BBBEE certificate or EME letter is valid for twelve months, it is therefore imperative for service providers to regularly

update their BEE status in order to be eligible for BEE preferential points.

SECTION 9

10. CLASSIFICATION FOR NMB SUPPLIER DATABASE

IN ORDER TO BE IDENTIFIED / SOURCED AS A POTENTIAL SERVICE PROVIDER, YOUR BUSINESS

NEEDS TO BE CLASSIFIED CORRECTLY.

Tick the appropriate block to indicate the correct classification of your company as a service provider:

Goods &

Services

Engineering &

Construction

Built Environment Consultant /

Professional Service

Provider

Education, Training &

Development

Legal Service

Provider

To assist us in the categorisation process and to ensure that your company is correctly classified, we

require a short summary of your core business, key words that best describe your business operations

and any specialisations.

Complete the following if you are service provider of the Goods and Services / Engineering Construction:

Our core business is:

Key Words:

Specialisations:

Additional classification pages are to be completed by service providers in the Built Environment

Professional Services / Legal Service Provider / Education, Training and Development.

Supplier Comments:

SECTION 10

Commodity

Group Description of Commodity Group

Tick the

applicable

block/s

Commodity

Group Description of Commodity Group

Tick the

applicable

block/s

10000000

Live Plant and Animal Material and

Accessories and Supplies 50000000

Food Beverage and Tobacco

Products

11000000

Mineral and Textile and Inedible

Plant and Animal Materials 51000000 Drugs and Pharmaceutical Products

12000000

Chemicals including Bio Chemicals

and Gas Materials 52000000

Domestic Appliances and Supplies

and Consumer Electronic Products

13000000

Resin and Rosin and Rubber and

Foam and Film and Elastomeric

Materials 53000000

Apparel and Luggage and Personal

Care Products

14000000 Paper Materials and Products 54000000

Timepieces and Jewelry and

Gemstone Products

15000000

Fuels and Fuel Additives and

Lubricants and Anti corrosive

Materials 55000000 Published Products

20000000

Mining and Well Drilling Machinery

and Accessories 56000000 Furniture and Furnishings

21000000

Farming and Fishing and Forestry

and Wildlife Machinery and

Accessories 60000000

Musical Instruments and Games and

Toys and Arts and Crafts and

Educational Equipment and

Materials and Accessories and

Supplies

22000000

Building and Construction Machinery

and Accessories 70000000

Farming and Fishing and Forestry

and Wildlife Contracting Services

23000000

Industrial Manufacturing and

Processing Machinery and

Accessories 71000000 Mining and oil and gas services

24000000

Material Handling and Conditioning

and Storage Machinery and their

Accessories and Supplies 72000000

Building and Facility Construction

and Maintenance Services

25000000

Commercial and Military and Private

Vehicles and their Accessories and

Components 73000000

Industrial Production and

Manufacturing Services

26000000

Power Generation and Distribution

Machinery and Accessories 76000000 Industrial Cleaning Services

27000000 Tools and General Machinery 77000000 Environmental Services

30000000

Structures and Building and

Construction and Manufacturing

Components and Supplies 78000000

Transportation and Storage and Mail

Services

31000000

Manufacturing Components and

Supplies 80000000

Management and Business

Professionals and Administrative

Services

32000000 Electronic Components and Supplies 81000000

Engineering and Research and

Technology Based Services

39000000

Electrical Systems and Lighting and

Components and Accessories and

Supplies 82000000

Editorial and Design and Graphic

and Fine Art Services

40000000

Distribution and Conditioning

Systems and Equipment and

Components 83000000

Public Utilities and Public Sector

Related Services

41000000

Laboratory and Measuring and

Observing and Testing Equipment 84000000 Financial and Insurance Services

42000000

Medical Equipment and Accessories

and Supplies 85000000 Healthcare Services

43000000

Information Technology Broadcasting

and Telecommunications 86000000 Education and Training Services

44000000

Office Equipment and Accessories

and Supplies 90000000

Travel and Food and Lodging and

Entertainment Services

45000000

Printing and Photographic and Audio

and Visual Equipment and Supplies 91000000 Personal and Domestic Services

46000000

Defense and Law Enforcement and

Security and Safety Equipment and

Supplies 92000000

National Defense and Public Order

and Security and Safety Services

47000000 Cleaning Equipment and Supplies 93000000 Politics and Civic Affairs Services

48000000

Service Industry Machinery and

Equipment and Supplies 94000000 Organizations and Clubs

49000000

Sports and Recreational Equipment

and Supplies and Accessories 95000000

Land and Buildings and Structures

and Thoroughfares

SECTION 11

Declaration in terms of Regulations 44 and 45 of the

MFMA Supply Chain Management Regulations

by

__________________________________

(the ‘Supplier’)

vis a vis the

Nelson Mandela Bay Metropolitan Municipality

(‘NMMM’)

1. No bid will be accepted from persons in the service of the state.

2. Any person, having a kinship with persons in the service of the state, including a blood relationship, may register as a prospective supplier.

3. In order to give effect to the above, the following questionnaire must be completed by company’s directors, managers, principal shareholders or stakeholders or duly authorised person

3.1 Full Name: …………………………………………………………………………

3.2 Identity Number: ….…………………………………………………………………

3.3 Company Name:….…………………………………………………………………

3.3.1 Company Registration Number:……………………………………………………

3.4 Are you presently in the service of the state YES / NO

3.4.1 If so, furnish particulars.

Name of employer: …………………………………………………….

Saff / Man / Persal number: ……………………………...

Employer’s address: ……………………………………………………... ……………………………………………………..

Designation: …………………………….. ……………………………..

3.5 Have you been in the service of the state for the past YES / NO

twelve months?

3.5.1 If so, furnish particulars.

Name of previous employer: …………………………………………………….

Saff / Man / Persal number: ……………………………...

Address: ……………………………………………………... ……………………………………………………..

Position held: …………………………….. ……………………………..

3.6 Are any of the company’s directors, managers, principal YES / NO

shareholders or stakeholders in service of the state?

3.6.1 If so furnish particulars Name of employer: …………………………………………………….

Saff / Man / Persal number: ……………………………...

Employer’s address: ……………………………………………………... ……………………………………………………..

Designation: …………………………….. ……………………………..

SECTION 12

3.7 Are any spouse, child or parent of the company’s directors, YES / NO

managers, principal shareholders or stakeholders in service of the state?

3.7.1 If so, furnish particulars. Name of employer: …………………………………………………….

Saff / Man / Persal number: ……………………………...

Employer’s address: ……………………………………………………... ……………………………………………………..

Designation: …………………………….. ……………………………..

CERTIFICATION

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

CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS CORRECT.

I ACCEPT THAT THE STATE MAY ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO

BE FALSE.

……………………………………… ……………………………………..

ID Number Position …………………………………. ………………………………………

Signature Date

MSCM Regulations: “in the service of the state” means to be – (a) a member of –

(i) any municipal council; (ii) any provincial legislature; or (iii) the national Assembly or the national Council of provinces;

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

Undertaking by

__________________________________

(the ‘Supplier’)

vis a vis the

Nelson Mandela Metropolitan Municipality

(‘NMMM’)

Whereas:

(a) the Supplier delivers goods or renders services to NMMM;

(b) NMMM is liable to pay the Supplier for goods delivered or services rendered; and

(c) the Supplier is liable pay NMMM for any due municipal rates and taxes or municipal service charges and any other indebtedness owed by the Supplier to the NMMM

Now therefore the Supplier undertakes the following:

1. In the event of the Supplier being in arrears in respect of any municipal rates and taxes or municipal service charges and any other indebtedness owed by the Supplier to the NMMM; which is / are due:

1.1 the Supplier shall make satisfactory and reasonable written settlement arrangements with the NMMM for the payment thereof; and

1.2 failing which, the NMMM may set-off any such due Municipal rates and taxes or Municipal service charges and any other indebtedness owed by the Supplier to the NMMM, from any amount owed by the NMMM to the Supplier;

2. To co-operate with the NMMM and to do all things and sign all such documents (and/or procure same to be done) as may be necessary or requisite in order to give proper and due effect to the terms of this undertaking or any matter arising there from in accordance with its intent and purpose;

3. No extension of time or indulgence granted by the NMMM shall be deemed in any way to affect, prejudice or derogate from its rights in any respect in terms of this undertaking, nor shall it in any way be regarded as a waiver of any of the NMMM’s rights hereunder; and

4. The Supplier shall not be entitled to cede any of its right’s nor delegate any of its obligations in terms of this undertaking to any other person without the prior written consent of the NMMM.

Thus done and signed by the Supplier at _____________________________________on _________ 201_

__________________________________

(The Supplier) duly authorised

SECTION 13