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. WWW Address: Telephone Number: 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 VAT No: Clearance Certificate): 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. Page 2
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: Hours of access to Tender Box: Information to be marked on envelope containing application: 44 Grand Central Boulevard, Midrand (Off R101 Old Johannesburg Road) Between 07:00 and 17:00 (Weekdays only) Gautrain Management Agency SCM Unit SUPPLIER DATABASE REGISTRATION - 2016 Name of Supplier: Page 3
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: Page 4
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: Page 5
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 Page 6
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:... Page 7
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 Page 8
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 Page 9
LIST OF COMMODITIES ANNEXURE A 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. Electronic Media Outdoor Media Advertising (Placement of Advertisements 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 Page 10
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) Page 11
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 Page 12
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 Page 13
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 Page 14
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 Page 15
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) Page 16