1
APPLICATION FOR REGISTRATION
ILEMBE DISTRICT MUNICIPALITY
DATABASE
KwaZulu-Natal
THESE FORMS MUST BE COMPLETED AND SUBMITTED TO:
SUPPLY CHAIN MANANAGEMENT OFFICE GROUND FLOOR
ILEMBE TECHNICAL SERVICES BUILDING
12 HAYSOM ROAD
KWA DUKUZA
4450
OR POSTED TO :
SUPPLY CHAIN MANAGEMENT (DEPARTMENT)
P. O BOX 1788
KWADUKUZA
4450
ENQUIRIES :
Tel: 032-5518753 /032 5518757
FOR OFFICIAL PURPOSES ONLY
NAME OF SUPPLIER: .....................................................................................
REGISTRATION NUMBER: ......................................................................................
2
INTRODUCTION AND GUIDELINES
The form was specifically designed to provide for the registration of suppliers on the Ilembe District Municipality
Suppliers Database. In order to ensure that suppliers are considered legitimate tenderers, it is
imperative that the following guidelines are adhered to.
Applicants must complete pages 2 to 8, where applicable. Failure by an applicant to provide ALL
relevant information and documents required will result in non-registration. If the information required is
not applicable to your business; clearly insert the symbols “N/A” in the appropriate space. If the space
provided is left blank, it will be regarded as information that is still outstanding and you WILL NOT be
registered.
Applicants are advised that only ORIGINAL IDM or PHOTOSTAT copies thereof will be processed. Any
Document that has been retyped or redrafted will be disregarded and returned to the applicant.
It is imperative that only documents with an ORIGINAL signature be submitted.
All signatures to the document must be commissioned by an authorized Commissioner of Oaths. Failure
to do so will result in the applicant not qualifying for registration.
A supplier registered on the Suppliers Database MUST notify the Supply Chain Management Office of any
changes to information provided in the initial IDM . Failure to do so may result in such a supplier being
removed from the Suppliers Database and/or the cancellation of contracts awarded to the supplier, on
the basis of misrepresentation.
Suppliers providing information incorrectly or fraudulently in their IDM will be disqualified from tendering
and removed from the Suppliers Database, in addition to any other action the Council may institute
against such a supplier. Further, in the event of the Council being prejudiced financially, it reserves the
right to take legal action against the supplier.
For definitions of terminology used in this document, please refer to the definitions set out in regulation 1
of the Procurement Regulations, 2001, obtainable from the SCM Office or website.
Any alterations made by the tenderer must be initialed. The use of correcting fluid is prohibited and the
use thereof will lead to non-registration of the applicant business.
Electronic forms are available on the website: www.ilembedistrictmunicipalitygov.za
APPLICATION FOR REGISTRATION ON ILEMBE DISTRICT MUNICIPALITY SUPPLIERS DATABASE
(The following information must be filled in by the applicant. Failure to submit ALL the required
information may lead to non-registration of the applicant business)
1. BUSINESS PARTICULARS:
1.1 Name of Business as registered with the Registrar of Companies/Close Corporations
________________________________________________________________________________________________
1.2 Name of business used for TRADING purposes, if different from 1.1 or name of business if business is
not registered with the Registrar
________________________________________________________________________________________________
1.3 Registration Number as registered with the Registrar of companies/close corporations (if
applicable):
____________________________________________
1.4 Postal address
________________________________________________________________________________________________
________________________________________________________________________________________________
Postal Code: _____________________
3
Physical address
________________________________________________________________________________________________
________________________________________________________________________________________________
Postal Code: ____________________
Telephone no. : (______) _______________________ Fax no.: (______) _________________________________
Cell. no. : ___________________________________
E-mail address (if available): _____________________________________________________________________
Preferred method of Communication: Email Fax Post
1.5 Contact person: ____________________________________________________________________________
1.6 Physical location of Head Office (if applicable) ________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
1.7 Unemployment Insurance Fund no. (if applicable) : ____________________________________________
1.8 Compensation Commissioner registration no. (If applicable): ___________________________________
1.9 Income Tax Reference Number : ______________________________________________________________
N.B. *Insert personal income tax no. if a one person business (Sole Proprietor) and Personal Income
Tax Numbers of all partners in a partnership. If insufficient space kindly attach information with
original signature.
1.10 P.A.Y.E. Number (if applicable) _______________________________________________________________
N.B. COPIES OF REGISTRATION CERTIFICATES FOR 1.7 AND 1.8 MUST BE SUPPLIED
(If you cannot provide these certificates, kindly attach explanation)
2. BANKING DETAILS
2.1 Name of banking institution: _________________________________________________________
2.2 Branch Name: ______________________________________________________________________
2.3 Branch Code: __________________________________________________________________________
2.4 Banking account number: ___________________________________________________________
2.5 Account Holder (Name under which account is operated):
_________________________________________________________________________________________
N. B. A COPY OR ORIGINAL BANK STATEMENT NOT OLDER THAN 60 DAYS MUST BE SUPPLIED.
4
3. TYPE OF BUSINESS
3.1 Tick whichever block is applicable to your business or firm and attach the relevant certified copy.
PUBLIC COMPANY LTD CERTIFIED COPY OF CERTIFICATE OF
INCORPORATION (CM 3)
PRIVATE COMPANY (PTY) LTD CERTIFIED COPY OF CERTIFICATE OF
INCORPORATION (CM 3)
CLOSE CORPORATION CC CERTIFIED COPY OF CK 1 DOCUMENT AND CK
2 IF APPLICABLE
SOLE PROPRIETOR CERTIFIED COPY OF I.D. DOCUMENT
PARTNERSHIP CERTIFIED COPY OF PARTNERSHIP AGREEMENT
TRUST CERTIFIED COPY OF TRUST DOCUMENT
CO-OPERATIVE CERTIFIED COPY OF PROOF OF REGISTRATION
WITH
THE DIRECTORATE CO-OPERATIVES
VOLUNTARY ASSOCIATIONS
CERTIFIED COPY OF CONSTITUTION
4. PREVIOUS BUSINESS INFORMATION
4.1 Did your business exist under a previous name? (Answer to be encircled) Yes or No
_________________________
4.2 If “yes” what was the previous business name?
_____________________________________________________________________________________________
4.3 Why was the name changed?
________________________________________________________________________________________________
________________________________________________________________________________________________
4.4 Previous Suppliers Database registration number: _____________________________________________
4.5 Who were the owners, partners, members or shareholders?
NAME TITLE
5
5. BUSINESS CLASSIFICATION FOR KWAZULU NATAL SUPPLIER DATABASE (M A N D A T O R Y)
Please tick appropriate classification /type (only ONE)
CODE CLASSIFICATION
D100 Supplier
D200 Main Contractor
D300 Sub-contractor
D400 Labour-only Contractor
D500 Consultant
D600 Manufacturer
D700 Professional Services
D800 Education,Development,Training
5.1 CLASSIFICATION OF BUSSINESS AND CATEGORY*
Please tick the appropriate
COMMODITY CODE COMMODITY DESCRIPTION
D101 Stationery
D102 Printing
D103 Cleaning materials
D104 Cleaning equipment
D105 Vehicle maintenance & repairs
D106 Office maintenance
D107 Office equipment
D108 Catering
D109 Office furniture
D110 Computer hardware, software, development
D111 Network solutions etc
D112 Travel agent, conference facilities
D113 Accommodation and car rental
D114 Courier services
D115 Media/publicity/advertising
D116 Promotional materials
D117 Vehicle purchasing
D118 Office maintenance
D119 Insurance brokers
D120 Computer accessories
D121 Consumables
D122 Entertainment
D123 Publishing
D124 Books
D125 Fuel, oil, tyres and gas
D126 Auctioneers
D127 Security Services
D128 Pest control
D129 Painting
D130 Plumbing
D131 Electrical Repairs
6
D132 Renovations
D133 Fumigation
D134 Carpet Cleaning
D135 Car Wash
D201 Training and development
D202 Organisational development
D203 Legal compliance
D204 Job evaluation
D205 Industrial relations training
D301 Health, safety and environment
D302 Health services
D303 Medical Consumables
D304 Medical instruments
D305 Linen, pillows and blankets
D401 Corporate Finance.
D402 Financial Management
D403 Tax Consulting Services
D404 Audit consulting services
D405 Payroll systems consulting
D406 Financial systems consulting
D407 Banking Services
D501 Sockets
D502 Valves
D503 Wire
D504 Tees, couplings, ferrules etc
D505 Tubes
D506 Hose taps
D507 Packings
D508 Water meters
D509 Miscellaneous water equipment
D601 Bolts & nuts
D602 Building material
D603 Nails
D604 Locks
D605 Cement
D606 Tools
D607 Pipes & accessories
D608 Window glass
D609 Corrugated iron
D610 Other specify
D701 Building contractors
D702 Consulting engineers
D703 Electrical engineers
D704 Mechanical engineers
D705 Land surveyors
D706 Architects
D707 Water treatment chemicals
7
D708 Telemetry systems& maintenance
D709 Plant hire
D710 Safety equipment
D711 Town & development planning
D712 Environmental
D713 Strategic planning
D714 Economic development
Our core business is: _________________________________________________________________
Products/Services: ___________________________________ ______________________________________
___________________________________ _______________________________________
___________________________________ ________________________________________
___________________________________ ________________________________________
5.2 INDICATE VALUE FOR THE FOLLOWING BASED ON THE LATEST FINANCIAL STATEMENT
5.2.1 Total Fixed Assets @ Book Value (e.g land, buildings, plant, equipment,
vehicles) R _____________
5.2.2 Vehicles @ Book value R _____________
Number of vehicles _____________
5.2.3 Average stock on hand R _____________
5.2.4 Cost of goods produced annually R _____________
Quantity produced annually _____________
Units of measure (e.g. tons, kilolitres) _____________
5.2.5 Total Current assets (e.g. stock, debtors, cash) R _____________
Total Current liabilities (e.g. creditors, bank overdraft) R _____________
8
6. BUSINESS INFORMATION
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 ACT 102 OF 1996. SELECT THE SECTOR AND TICK THE APPROPRIATE BLOCKS IN COLUMN 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 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 R19m
Electricity, Gas and Water
MORE THAN 200 MORE THAN R 5m MORE THAN R 19m
LESS THAN 200 LESS THAN R 5m 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 R10m
LESS THAN 100 LESS THAN R 64m LESS THAN R 10m
Catering, Accomodation & Other Trade
MORE THAN 100 MORE THAN R 13m MORE THAN R 3m
LESS THAN 100 LESS THAN R 13m LESS THAN R 3m
Transports, Storage and Communications
MORE THAN 100 MORE THAN R 26 m 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 R13m MORE THAN 6m
LESS THAN 100 LESS THAN R13m LESS THAN R 6m
9
7. PROPRIETORS /SHAREHOLDERS/PARTNERS/SOLE PROPRIETORS/TRUSTEES/BENEFICIARIES (OWNER)
7.1 List all persons who are OWNERS (as listed above), in the business/trust, and indicate their involvement in the management/operations of the
business/trust.
7.2 PROOF OF DISABILITY PROVIDED BY A RECOGNISED RELATED INSTITUTION, IN THE CASE OF HANDICAPPED PERSONS, MUST BE SUPPLIED.
7.3 If insufficient space, kindly attach a copy/copies of this page to this form, signed by the same person who signs on behalf of the business/trust on
page 6 hereof.
BUSSINESS OWNERSHIP
FULL NAME ID NUMBER SA
CITIZEN
YES /NO
SA
CITEZEN
BEFORE
27 APRIL
1994
YES/NO
CAPACITY:
MEMBER/PARTNER
/ SHAREHOLDERS/
TRUSTEE, etc
% OWNERSHIP/
PARTNERSHIP/
TRUST/ INTEREST
HDI
YES/NO
MALE /
FEMALE
HANDICAPPED YOUTH
OWNED
YES/NO
% OF
TIME
DEVOTED
TO THE
FIRM
10
8. PREVIOUS EXPERIENCE (IF APPLICABLE)
List the last 4 contracts awarded to you (the supplier) or other previous experience related to your
core business.
EMPLOYER
/DEPARTMENT
CONTACT PERSON
and TELEPHONE
NO.
CONTRACT
VALUE IN RAND
COMPLETED
SUCCESSFULLY
YES /NO
YEAR
9. PLEASE INDICATE ANY OWNER WHO HAS A CONTROLLING OWNERSHIP INTEREST IN ANOTHER BUSINESS
NAME OF OWNER NAME AND
ADDRESS OF
OTHER BUSSINESS
POSITION HELD % OF OWNWERSHIP TYPE OF BUSINESS
10. IDENTIFY BY NAME, HDI STATUS AND LENGTH OF SERVICE, THOSE INDIVIDUALS IN THE FIRM
(INCLUDING OWNERS AND NON OWNERS) RESPONSIBLE FOR DAY TO DAY MANAGEMENT AND
BUSINESS DECISIONS.
NAME HDI STATUS
(YES /NO)
LEGTH OF SERVICE
(YEARS)
CHEQUE SIGNING
SIGNING AND CO-SIGNING
FOR LOANS
BUSINESS FINANCE (overdraft,
lease agreements)
SURETIES
APPROVAL MAJOR PUCHASES
OR ACQUISITIONS
SIGNING CONTRACTS
11
DECLARATION: CONFLICT 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 □ No
NOTE: “in the service of the state” means –
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 municipality entity;
c) an official of any municipality or municipal entity;
d) 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)
e) a member of the accounting authority of any national or provincial public entity; or
f) an employee of Parliament or a provincial legislature.
If “YES” please state the nature of the relationship
Employee Name: ________________________
Salary Number: _______________________
12
11. VERIFICATION OF INFORMATION SUPPLIED RELATING TO PREFERENCES THAT THE
APPLICANT(BUSINESS) MAY APPLY FOR
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 (ZNT 31)
INCLUDING THE ANNEXURE/S WITH ADDITIONAL INFORMATION, IS CORRECT AND ACCURATE AND
ACKNOWLEDGES THAT:
1. The supplier will be required to furnish documentary proof of the information relating to
preferences, if requested to do so.
2. If the information supplied is found to be incorrect then the Council may, in addition to any
remedies it may have:
i. Disqualify the supplier/contractor for a particular tender/contract/project it may be
considered for, or which had been awarded to the supplier/contractor;
ii. Recover from the supplier/contractor all costs, losses or damages incurred or sustained by the
Council as a result of breach of the contract;
iii. Cancel the contract and claim any damages which the Province may suffer by having to
make less favourable arrangements after such cancellation: and/or;
iv. iv. De-register the supplier registered on the Supplier Database
SIGNED ON THIS _________ DAY OF _________________20________ AT _________________________________
BEFORE THE COMMISSIONER OF OATHS
___________________________________________
SIGNATURE OF AUTHORIZED REPRESENTATIVE
____________________________
NAME IN BLOCK LETTERS
SUPPLIER’S NAME: ________________________________________________________________________
Signed and affirmed to, before me at, _____________________________________________ on this
__________day of ___________________ year ___________, by the deponent who has acknowledged that
he/she knows and understands, the contents of this document, and he/she has acknowledged that
he/she has no objection to affirming, that he/she regards the affirmation to be binding on his/her
conscience.
____________________________
COMMISSIONER OF OATHS
FULL NAME:
____________________________________________________________________________________________________
BUSINESS ADDRESS :
____________________________________________________________________________________________________
CAPACITY : ___________________________________________________
AREA : ________________________________________________________
13
* MANDATORY INFORMATION
ANNEXURE “A”
Required document checklist
Please ensure that all documentation listed below is attached (where applicable) to the registration
form.
Document Name Attached
Duly completed suppliers database form □
Company Registration Documents □
Certified copies of Identity Documents of directors/owners/members/shareholders □
Banking Details and attach the recent bank statement □
Original Valid Tax Clearance Certificate □
Latest statements or bills on municipal services charges (electricity, water and sanitation,
rates etc). □
Compensation of Occupational Injuries and Diseases (COID)Registration Certificates(if applicable )□
All relevant registration certificate pertaining to your business, incl. but not limited to (if applicable)
NHBRC Registration Certificate □
CIDB Registration Certificate □
SETA Registration □
SAQA pertaining to business sector □
Trade test certificates □
SOB Registration □
Membership certificates for professional services □
FOR OFFICE USE ONLY
RECEIPT NO: _______________________________________
CAPTURED BY: _____________________________________
CHECKED BY: ______________________________________
VERIFIED BY: ______________________________________