Application Form for Suppliers

Greater GiyaniMunicipality

Application form for suppliers

GREATER GIYANIMUNICIPALITY

TEL: (015) 812 3707 P/BAG X 9559

FAX: (015) 812 2068 GIYANI 0826

OFFICE OF THE MUNICIPAL MANAGER

GREATER GIYANIMUNICIPALITY

Application form for Close Corporations, Section 21 Co, Trust, Partnership and Parastatal

Service includes, Catering, Professional services, Designers etc

A. PERSONAL DETAILS

Name of the business (print in full)

Legal Status (Please tick in the applicable column)

Section 21 Company / Partnership
Trust / Sole Trader
Close Corporation / Parastatal
NGO
Other (Please specify)

Business Postal Address

Code

Business Physical Address

Code

Business Telephone No

Business Fax No

E-mail address

Contact Person (Print names in full)

First Names

Surname

Telephone No (Work)

Cell Phone No

Reference

List at least two clients from the above companies that would be able to serve as references:

Client name / Discipline / Contact person / Position / Tel. Number

B. REGISTRATION DETAILS

Business (Company) Registration No

Professional Registration No

Vat Registration No

Income Tax Registration No

Registration Date

Note

A tax clearance certificate should be attached to this application forms.

C. OWNERSHIP

C1. Personal Information (Owner 1)

First names

Surname

Identity No/Passport No

Gender (Tick in the applicable column)

Male
Female

Citizenship

Home Language

Postal Address

Code

Physical Address (if different from postal address)

Code

Contact No

Work

Cell No

Fax No

C2. Personal Information (Owner 2)

First names

Surname

Gender (Tick in the applicable column)

Male
Female

Identity No/Passport No

Citizenship

Home Language

Postal Address

Code

Physical Address (if different from the postal address)

Code

Contact No

Work

Cell No

Fax No

C3. Personal Information (Owner 3)

First names

Surname

Identity No/Passport No

Gender (Tick in the applicable column)

Male
Female

Citizenship

Home Language

Postal Address

Code

Physical Address (if different from the postal address)

Code

Contact No

Work

Cell No

Fax No

C4. Relationships with the Municipality

Are any of the owners’ currently employed by the Municipality?Yes/ No

If yes, please provide details:

Are any family members of the owners currently employed by the Municipality?Yes/ No

If yes, please provide details:

Are any of the owners members of Council?Yes/ No

If yes, please provide details:

C.5 Interest of shareholders in other consulting firms

Name of person / Name of other firm / Type of business / Nature of interest / % of ownership

D. BUSINESS STRUCTURE

Please indicate the percentage of population group and sex represented in your business.

The percentage of ownership in the business

MaleFemale

White (in %)

Black (in %)

Coloured (in%)

Asian (in%)

Disabled (in%)

The percentage of management in the business

MaleFemale

White (in %)

Black (in %)

Coloured (in%)

Asian (in%)

Disabled (in%)

E. PARTICULARS OF PRODUCTS AND SERVICES

Please tick the appropriate block:

Products

/

Services

Computer Hardware / Cleaning of services
Computer software / Repairs to vehicles
Stationery / Community services
Information technology / Economies
Financial services
Project management
Catering

Other:

F. PAYMENT ARRANGEMENT

F1. Credit terms:

No credit terms

30 days

60 days

Other (Specify):

F2. Interest rates on overdue account:

F3. Details of discounts:

F4. Details of guarantees on goods and services:

F5. Details of bank account:

Name of account holder

Bank Name

Branch

Branch code

Bank account number

Bank account type (please tick in the appropriate block)

Saving Account

Cheque Account

Transmission Account

G. Past experience

G1. Specify the name of the firms with which you have conducted joint venture consulting projects or with which you have a close association

Name of the firm / Partner-based local/international / Name of project / Partner specialization area / % of work to partner

G2. Annual turnover of own work ( tick in the applicable block)

Income Level

Below current VAT threshold (R 300 000)
Between VAT threshold and R1 million
Between R2 million and R5 million
Between R5 million and R15 million

G3. Most recent projects undertaken (started or finished within the last 3 years)

Client Name / Description of the project / Location where the project was undertaken / Project Value

H. Company profile

H1. Provide an overview on the company profile in key words not exceeding 150 words

I. Employer profile, employment equity and skills development

I1. Number of employees

Category / Total number of employees inclusive of PDL’s / PDI
Prof / Tech / Admin / Total / Prof / Tech / Admin / Total
Full time
Part time
Female (white)
Female (male)
Male (white)
Male (Black)
Disabled

Greater GiyaniMunicipality

Application form for suppliers

DECLARATION

Detailed declaration / Yes or No
The firm agrees to abide by any reasonable and acceptable code of conduct published by the client organization
All the information supplied in this application is true and correct
The firm will, without protest, submit to all reasonable and acceptable procedures instituted by the client organization
The firm will, if requested to do so, supply further information and documents serving as evidence for scrutiny
The firm will update the registration particulars whenever a significant change in details occurs and, in any event annually.

The undersigned, who warrants that she/he is duly authorized to do so on behalf of the firm, confirms that the contents of this affidavit are within their personal knowledge and, save where otherwise stated, to the best of their knowledge, both true and correct.

Signed(Name in full)Duly authorized to sign on behalf of:

Signedon theday of (month) (year)

By the deponent, who has acknowledged that she/ he knows and understand the contents of this Affidavit, that is true and correct to the best of her/ his knowledge and that she/ he has no objection to taking the prescribed oath, and that the prescribed oath will be binding on her/his conscience.

Commissioner of Oaths:

Declaration of PDI professional service provider status

The undersigned, who warrants that she/he is duly authorised to do so on behalf of the firm, confirms that the firm complies with the requirements for registration as a PDI professional service provider as defined, and the contents Affidavit are within the personal knowledge and save where otherwise stated, to the best of their knowledge, true and correct.

Signed (Name in full)Duly authorized to sign on behalf of:

Signedon theday of (month) (year)

By the deponent, who has acknowledged that she/ he knows and understand the contents of this Affidavit, that is true and correct to the best of her/ his knowledge and that she/ he has no objection to taking the prescribed oath, and that the prescribed oath will be binding on her/his conscience.

Commissioner of Oaths:

For Office Use Only

Accepted by Greater GiyaniMunicipality

Name……………………………

Signature…………………….

Date…………………………….

Suppliers file created

Name……………………………

Signature…………………….

Date…………………………….

Suppliers database updated

Name……………………………

Signature…………………….

Date…………………………….

Categories of Service Providers

Category / Service Provider / Registration Fee
A / Engineering / R265.00
B / Construction / R159.00
C / Personal and Supplier / R106.00
D / Catering / R 80.00

Banking details

Bank Name: First National Bank

Account Name:Greater GiyaniMunicipality

Branch Name:Giyani

Branch Code:260649

Account Number:62024288103