SUPPLIER DATABASE REGISTRATION FORM 2

1 ZululandZululandZululandZululand DISTRICT MUNICIPALITY UMKHANDLU WESIFUNDA SUPPLIERS DATABASE REGISTRATION form DELIVER TO: PROCUREMENT OFFICER QUEEN SILOMO CENTRE ZULULAND DISTRICT MUNICIPALITY OFFICES PRINCESS MKABAYI STREET ULUNDI OR POST TO: THE PROCUREMENT OFFICER ZULULAND DISTRICT MUNICIPALITY PRIVATE BAG X 76 ULUNDI 3838 ALL ENQUIRIES TO BE DIRECTED TO: THE PROCUREMENT OFFICER TELEPHONE: 035-874 5516 FAX NUMBER: 035-874 5589/91 FOR OFFICE USE SUPPLIER Name: _____ ZDM REGISTRATION Number: ZDMDB_____ Captured By: _____ Date:_____ Approved By: _____ Date:_____ 2 section A: INSTRUCTIONS INTRODUCTION The ZDMDB form was specifically designed to provide for the REGISTRATION of suppliers on the Zululand District Municipality s suppliers DATABASE .

2 In order to ensure that suppliers are considered legitimate, it is imperative that the following guidelines are adhered to. GUIDELINES Applicants must complete pages 2 to 16, where applicable. Failure by an applicant to provide ALL the prescribed 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. All mandatory fields marked by two asterisks** are to be filled in. If the space provided is left blank and or mandatory fields are not filled in, it will be regarded as information that is still outstanding and you WILL NOT be registered. Only black ink is to be used when filling in the form .

3 1. Applicants are advised that only ORIGINAL ZDMDB form or PHOTOSTAT copies thereof will be processed. Any document that has been retyped or redrafted will be disregarded and returned to the applicant. 2. It is imperative that only supporting documents with an ORIGINAL signature be submitted. 3. 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 . 4. A SUPPLIER registered on the Suppliers DATABASE MUST notify the Supply Chain Management Office of any changes to information provided in the initial ZDMDB form , as captured onto the Suppliers DATABASE . Failure to 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.

4 5. Suppliers providing information incorrectly or fraudulently in their ZDMDB form will be disqualified from bidding and removed from the Suppliers DATABASE , in addition to any other action the Province may institute against such a SUPPLIER . Furthermore, in the event of the province being prejudiced financially, it reserves the right to take legal action against the SUPPLIER . 6. For definitions of terminology used in this document, please refer to the definitions set out in Treasury Regulation 16A and the Zululand District Municipality s Supply Chain Management Policy Framework, located on the Zululand District Municipality s website, 7. Any alterations made by the SUPPLIER to its own information inserted on this document, must be initiated by the SUPPLIER .

5 The use of correcting fluid is prohibited and the use thereof will lead to non- REGISTRATION of the applicant business/ SUPPLIER . 8. Reminder letters will be issued by the Zululand District Municipality to suppliers to update their information. It remains the responsibility of the SUPPLIER to ensure that their information is updated in the Suppliers DATABASE , therefore if a reminder letter is not received, the SUPPLIER must follow up with Zululand District Municipality. 9. Electronic forms are available on the website: , Select SUPPLIER DATABASE . 3 section B: COMPANY INFORMATION 1. Business particulars** 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 s business PLEASE USE BLOCK LETTERS.

6 Name of business as registered with Registrar of Companies Trading as Holding company REGISTRATION number of Company/CC/Trust/Fund no. Business Postal address Business Physical address Telephone number Fax number Cellular phone number E-mail address Website address Preferred language Contact person (Full Name & Surname) Physical location of Head Office (if applicable) 4 2. Financial information ** Name of bank Name of account holder Type of bank account Branch name Bank branch number (at least six numbers) Bank account number NB: A certified copy of latest bank statement or original cancelled cheque or Annexure A to be completed and confirmed by your bank. UIF number Compensation Commissioner REGISTRATION number Income Tax reference number Construction Industry Development Board REGISTRATION number (CIDB) PAYE number VAT REGISTRATION number Tax clearance certificate issue date Tax clearance certificate expiry date Financial year-end NB: A certified Tax Clearance Certificate must be attached.

7 3. Indicate the value of the below stated based on the latest financial statements** Total fixed at book value ( land, buildings, plants, equipment) Vehicles at book value Number of vehicles Average stock on hand Cost of goods produced annually Quantity produced annually Units of measure ( tons, kilolitres) Total current assets ( stock, debtors,cash) Total current liabilities ( creditors, bank overdraft) 5 4. Municipalities** Please clearly indicate, with an X , the District Municipality/s where your business operates. eThekwini Municipality (DC 20) Amajuba Municipality (DC 25) Ugu Municipality (DC 21) Zululand Municipality (DC 26) Umgungundlovu Municipality (DC 22) Umkhanyakude Municipality (DC 27) Uthukela Municipality (DC23) Uthungulu Municipality (DC 28) Umzinyathi Municipality (DC 24) Ilembe Municipality (DC 29) Sisonke Municipality (DC 47) 5.

8 Previous business information (if applicable) Did you business exist under a different name previously? If yes what was the previous business name? Reason for name change: 6. Business Sector** (Please see pages 8-9 for details Please indicate the sector applicable to your business. Core Business Area Agriculture Mining & Quarrying Manufacture Electricity, Gas & Water Construction Retail, Motor Trade & Repair Wholesale Trade & Commercial Catering, Accommodation, Other Transport & Storage Finance & Business Services Community, Social & Personal 6 7. Previous experience (if applicable)** List the last three (3) contracts awarded to you (the SUPPLIER ) or other previous experience related to your core business.)

9 CONTRACT 1 Employer / Department Contact person Initials Telephone number Was the project completed successfully? What year was the project initiated? What was the contact value? CONTRACT 2 Employer / Department Contact person Initials Telephone number Was the project completed successfully What year was the project initiated? What was the contact value? CONTRACT 3 Employer / Department Contact person Initials Telephone number Was the project completed successfully? What year was the project initiated? What was the contact value? 7 section C: CLASSIFICATION OF BUSINESS 1. Type of business** Please mark with an x the block applicable to your business or firm AND attach the relevant certified copy A.

10 Public Company LTD Certified copy of certificate of incorporation (CM1) Private Company (PTY) LTD Certified copy of certificate of incorporation ( CM1) Close Corporation CC Certified copy of CK 1 document and CK 2 if applicable Incorporated Certified copy of certificate of incorporation (CM1&CM29 Sole proprietor Certified copy of Identity document Partnership Certified copy of partnership agreement Trust Certified copy of trust document Co-operative Certified copy of proof of REGISTRATION with Directors Co. Welfare organization Certified copy of constitution Total Gross Asset value (fixed property excluded) Annual turnover Number of employees 8 2. Products & Services** In order to assist with the classification of suppliers, please indicate the industrial sector related to the goods/services that you supply.)