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1
SUPPLIER DATABASE
REGISTRATION
QUESTIONNAIRE
Name of company …………………
Town / City…………………………
FOR OFFICE USE ONLY Date Received: ________________________ Received by: __________________________ IDT Stamp:
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ALL SUPPLIER INFORMATION WILL BE TREATED STRICTLY CONFIDENTIAL. NOTE: a) The information required is mandatory. b) IDT reserves the right to conduct audits and investigations on any
applicant or information supplied in this questionnaire. c) Submit with your application the following documents:
1. An original cancelled cheque or an original stamped letter from the bank, verifying the banking details.(bank letter should not be older than 6 months old)
2. Copy of Company Registration documents. 3. Original Certified Copy of ID documents of Directors/owners/Members/
Shareholders. 4. Valid VAT certificate (where applicable). 5. Valid Tax Clearance Certificate (original). 6. Copy of registration certificate pertaining to your relevant industry. 7. Companies claiming Black Economic Empowerment as per IDT’s
definition (see below) to submit copies of the following:
7.1 An original or (original certified) copy of a BEE Certificate
8. Close Corporations to attach an Association Agreement (Not compulsory)
9. (Pty) Ltd.’s to attach Shareholders Agreement, Memorandum of Association as well as share certificates
The above documents to stipulate management responsibilities, profit sharing, liabilities/responsibilities, management contribution, protection in case of death etc.
BLACK ENTERPRISES
The following is a guide on how Independent Development Trust defines Black Enterprise Companies:
Definition: ‘Black’ means South African citizens who are Black, Indian or Coloured persons and EXCLUDES individuals belonging to such communities from any other country. Black Women-owned Enterprises (BWO):
At least 50% of the voting shares or interests are held and controlled by Black Women, and
Black Women have contributed at least 50% of the required capital, and
Black Women in the enterprise have not been given voting shares or interest just to capture or retain contracts, and
Black Women participate in the day to day management and decision making of the enterprise. They necessarily have the aptitude and potential to understand all issues involved in the running of the
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enterprise including knowledge of the product and market within which their enterprise operates.
In a joint venture, skill must be transferable to the Black Women entrepreneur, which means that the Black Women entrepreneur must have the required educational level and/or aptitude.
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SECTION A A1. BUSINESS INFORMATION
Title (Prof. / Dr / Mr / Mrs / Ms) and Surname: ____________________________________________ (If sole proprietor) ‘Trading as’ name of business: _________________________________________________________ (Contracts/order will be placed on this name and invoices must reflect it) Vat Registration Number: __________________________________ Business Tax Number: _______________________________________ Business Registration Number: _____________________________________ Firm’s Average Turnover: _______________________________________ Total Number of Full Time Employees: _______________________________ Total Number of Part Time Employees: _______________________________ Bodies / Institutes / Trade Assoc. Membership Details: _____________________________ Physical address of business: Building / complex name: __________________________________________________________ Street name and number: ___________________________________________________________ Suburb: _________________________________ City: ______________________________________ Code: __________________________________ Country: ____________________________________ Postal address of business: (This is the address to which an Invitation to render services and orders/contracts must be sent to) P O Box / Private Bag: ______________________City/Town: ________________________Code:_____ Telephone numbers of business: Code: ______ Number: ___________________ Accounts department (Tel no) Code_______ Number: ___________________
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Contact person fax number: Code: _______ Number_________________________ (Will be used by IDT for electronic faxing of Request for Services, Contracts and Purchase Orders) Business e-mail:_____________________________________________________________ Your own business contact person/marketing representative name and telephone number: _________________________________________________________________
If Applicable
Sole Proprietor Title (Prof. / Dr Mr / Mrs / Ms/): _________________________ Sole Proprietor Full Name:_________________________________________ Sole Proprietor ID Number: ________________________________________ Previous Name of Business: _______________________________________ Previous Owners of Business: ______________________________________ ______________________________________________________________
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SECTION B
B1. BANKING INFORMATION
Please attach an original cancelled cheque or an original bank verification letter (Not
older than 6 months)
Account Holder: ___________________________________
Bank Account number: _____________________________
Account type: _____________________________________
Bank: ___________________________________________
Branch Name: _____________________________________
Branch code: ______________________________________
Swift Code (Where Applicable):________________________
All payments will be made electronically directly to your bank account.
Kindly note that it will be your responsibility to inform the IDT, in writing, of any
changes in your banking details.
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KINDLY ENSURE THAT ALL THE SECTIONS BELOW ARE FULLY COMPLETED)
SECTION C: PEOPLE
EMPOWERMENT 1. EMPLOYMENT EQUITY
Black Economic Empowerment (BEE) A BALANCED SCORECARDS MEASURING BROAD BASED BEE SHALL BE USED IN THE ALLOCATION
OF BEE POINTS
LIST OF ALL PARTNERS, PROPRIETORS AND SHAREHOLDERS. (Re (Attach shareholders’ Certificate)
The IDT as a development Agency plans and tracks on a continuous basis, key development
indicators. These select indicators relate to participation of different socioeconomic cohorts. Of
particular importance in this instance is the level of participation of Women, Youth, and People with
disabilities and Black population in the context of South Africa. This information is critical and
Suppliers and service providers should complete this section. It is important to note that this
information is used for statistical, planning for impact as well as tracking and internal reporting on the
cited empowerment indicators.
C1.
COMPLETE THE FOLLOWING INFORMATION FOR EACH PARTNER, PROPRIETOR, SHAREHOLDER, DIRECTOR AND OFFICER OF THE FIRM (e.g. Chairman, Secretary, Director, etc.)
Name
ID: Number
Company OR Trust Reg. Number
Race Gender
M/F
Disabled
Yes/No
Shares
%
Home Address
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C2.
Shareholder’s % Breakdown
% Black Male % Black Female % Black Disabled
% % %
% White Male % White Female % White Disabled
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B2. INDICATE WITH (X) COMPANY B-BBEE RECOGNITION LEVEL
B-BBEE Status Level Contributor Single Entity Joint Venture /
Consortium*
LEVEL ONE CONTRIBUTOR
LEVEL TWO CONTRIBUTOR
LEVEL THREE CONTRIBUTOR
LEVEL FOUR CONTRIBUTOR
LEVEL FIVE CONTRIBUTOR
LEVEL SIX CONTRIBUTOR
LEVEL SEVEN CONTRIBUTOR
LEVEL EIGHT CONTRIBUTOR
NON-COMPLIANT CONTRIBUTOR
Exempted Micro Enterprise (EME)
EME LEVEL THREE CONTRIBUTOR
EME LEVEL FOUR CONTRIBUTOR
*For Unincorporated Joint Venture / Consortium: Consolidated B-BBEE certificate from SANAS, IRBA or any Credible Accredited Verification Agency must be provided
B8. INDICATE WITH (X) COMPANY CIDB RATING GRADE 1 GB OR GBPE
GRADE 2 GB OR GBPE
GRADE 3 GB OR GBPE
GRADE 4 GB OR GBPE
GRADE 5 GB OR GBPE
GRADE 6 GB OR GBPE
GRADE 7 GB OR GBPE
GRADE 8 GB OR GBPE
GRADE 9 GB
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B3. LIST OF ALL PARTNERS, PROPRIETORS AND SHAREHOLDERS.
(Re (Attach shareholders’ Certificate)
B4.
COMPLETE THE FOLLOWING INFORMATION FOR EACH PARTNER, PROPRIETOR, SHAREHOLDER, DIRECTOR AND OFFICER OF THE FIRM
(e.g. Chairman, Secretary, Director, etc.)
Name Race Gender
M/F
Disabled
Yes/No
% of time devoted to firm
Home Address
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(PLEASE ATTACH THE COMPANY’S EMPLOYMENT EQUITY TARGET FOR NEXT FIVE YEARS)
Management Details
List all Managers of the firm
C3.
IDENTIFY BY NAME, RACE, GENDER, DISABLILTY AND LENGTH OF SERVICE, THOSE INDIVIDUALS IN THE FIRM (INCLUDING OWNERS AND NON-OWNERS) RESPONSIBLE FOR DAY-TO-DAY MANAGEMENT AND BUSINESS DECISIONS
Activity Name Race Gender
M/F
Disabled
Yes/No
Manage %
Length of
Service (Years)
Financial Decisions
Management Details
CEO
CFO
Supervision of Field / Production Services
Supervision of Office Personnel
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BBBEE Recognition Level ______________________________________ Percentage Contributor_________________________________________ BBBEE Certificate Number______________________________________ Name of Company Listing BBBEE Certificate________________________________________ Scorecard Type: EME; QSE or GENERIC__________________________
C4.
BBBEE Information
C5.
CIDB GRADING FOR CONTRACTORS
Grade:_____________________
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SECTION D:
OFFICES
D1. LOCALITY/OFFICES PLEASE INDICATE WITH (X) AREAS WHERE YOUR BUSINESS CURRENTLY OPERATES/ AREAS OF REPRESENTATION:
Gauteng
North West
Free State
Mpumalanga
Northern Cape
Limpopo
Western Cape
Eastern Cape
Kwazulu-Natal
Kindly indicate: Head Office Branch Office (s) where represented only.
HEAD OFFICE PHYSICAL ADDRESS:
POSTAL ADDRESS:
CONTACT PERSON:
CONTACT NUMBERS:
EMAIL ADDRESS:
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BRANCHES
PHYSICAL ADDRESS:
POSTAL ADDRESS:
CONTACT PERSON:
CONTACT NUMBERS:
EMAIL ADDRESS:
Note that if the amount of branches exceeds the provided space,
please supply an attachment
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SECTION E: CAPACITY
1. CAPACITY AND PAST PERFORMANCE
E1.
LIST THE THREE LARGEST CONTRACTS/ASSIGNMENTS COMPLETED BY YOUR FIRM IN THE LAST FOUR YEARS
Work performed/Project
/Assignment
Client & Contact Person
Physical Address & Telephone number (land line & mobile)
Professional Fees/ Project Value
E2. LIST THE CURRENT PROJECTS/ASSIGNMENT THAT YOUR FIRM IS INVOLVED IN
Assignment Client Physical Address & Professional & Contact Person Telephone number Fees/Project Value (landline and mobile) 1. 2. 3. 4.
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E3. PREVIOUS APPOINTMENTS BY IDT
Project/Programme Name
Type of project
Contract Start
Contract End
Professional Fees/Project
Value
Financial year
IDT Contact Person & Tel
no.
E4. DID THE FIRM EXIST UNDER A PREVIOUS NAME? YES / NO IF YES, WHAT WAS THE NAME: ______________________________________________
E4.1 WHO WERE OWNERS/ PARTNERS/ DIRECTORS:
TECHNICAL E5. IS YOUR BUSINESS A PERMIT HOLDER UNDER THE SABS, MARK SCHEME? (Y / N )
…………………………………. IF YES, INDICATE PRODUCT(S) FOR WHICH PERMITS ARE HELD, INCLUDING PERMIT NUMBERS
QUALITY E6. HAS YOUR QUALITY MANAGEMENT SYSTEM BEEN ASSESSED & CERTIFIED BY ANY
NATIONAL / INTERNATIONALLY RECOGNISED ACCREDITED BODY (Y / N ) IF YES PROVIDE COPY OF CERTIFICATE.
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F1. TYPE OF FIRM (Tick applicable box)
Close Corporation
Co-Operatives
Company
Joint Venture
One Person Business / Sole Trader
NPO / NGO
Partnership
Trust
Educational Institutions
Section 21 Companies
Municipalities
Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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F.3
PROFESSIONAL CAPACITIES
( CONSULTANTS ) (Tick applicable box)
Consulting, Civil and Structural Engineering
Electrical Engineering
Mechanical Engineering
Project Management
Quantity Surveying
Social Facilitator
Architects
Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
F2. PARTICIPATION CAPACITIES (Tick applicable box)
Electrical / Mechanical Contractor
Joint Venture Partner
Main Contractor
Manufacturer
Prime Contractor
Professional Services
Specialist Sub-Contractor
Sub-Contractor
Supplier
Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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F4. PROFESSIONAL CAPACITIES
( CONTRACTORS ) (Tick applicable box)
Building Construction
Civil Construction
Electrical Engineering Works
Marine Construction
Mechanical Engineering Works
Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
F5. SAFETY (CONTRACTORS) (Tick applicable box)
1. Does your business have an Occupational Health Policy complying to the Occupational Health and Safety Act (OHSA) Yes/No
2. Are you registered with Compensation for Occupational Injuries and Diseases Act (COIDA) Yes/No
COIDA registration number_________________________________
F6. Human Resources
1. Briefly state your Affirmative Action (AA) Policy.
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F8. Proudly South African
Do you get more than 80% of your material from your Local Area
Geographically : Yes ______________________ No ______________________
Place
Nationally : Yes_______________________ No_______________________
Region
Internationally : Yes_______________________ No_______________________
Country
2. Are you registered with Compensation for Occupational for Occupational Injuries and Diseases Act (COIDA) Yes/No
COIDA registration number_________________________________
F7. NAME ALL THE BODIES/INSTITUTES/TRADE ASSOCIATIONS OF WHICH YOU HAVE MEMBERSHIP (E.g. The South African Council of Quantity Surveyors- Reg. No. 1589678)
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F8. Services Offered ( Please chose Three only) (Tick applicable box)
Agriculture Information Technology
Catering
Mining
Communications and related
Recruitment Agencies
Corporate
Retail
Electrical Engineers
Social Facilitators
Farming
Transport
Information Systems
Architectural
Manufacturing
Cleaners
Quantity Surveyors
Safety Clothing and Equipment
Research
Economist
Selected by Government
Events Management
Training and Education
Hospitality
Architects
Land Surveyors
Civil Engineers
Project Management
Construction
Rental / Hiring
Development Consultants
Security
Engineers
Stationery / Office Equipment
Financial
Wholesalers
Printing
Maintenance
Office Furniture Furniture Removals
Legal Land Surveyors
Wholesalers Research
Community, Social and Personal Insurance
Hospital Equipment Consultants
Relocation Services Garden Services
Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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SECTION G:
ATTACHMENTS (CONPLETION OF THIS SECTION IS COMPULSORY)
Please attach certified copies/original of the following documents:
Tick
Fully Completed Supplier Questionnaire
Cancelled cheque or an original bank verification letter
Original Certified Copies of ID Documents of owners / Directors etc.
Company Registration Documents
Shareholders agreements / certificates for companies
Original VAT certificate where applicable
Original valid Tax clearance certificate
Proof of registration with professional body where applicable
JV’S Agreement if any
Disability
Original Certified Copy of BEE Certificate (if Claiming BEE)
CIDB Registration Certificate
Utility Bill
Original Income Tax Exemption Certificate
NPO Registration Documents
Deed Of Trust
NB: The onus is on the supplier to ensure that updated (expiring) documents are submitted at the nearest IDT offices.
SWORN STATEMENT I/we, the undersigned, warrant that I/we am/are duly, authorised to do so, on behalf of the enterprise and certify that:
a) The information furnished is true and correct. b) If misrepresentation to gain any benefit is established, The
Independent Development Trust may in addition to any other remedy it may have
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disqualify the applicant;
restrict the applicant, its shareholders and directors from obtaining business from Independent Development Trust for a period not exceeding 5 years;
in the event that a contract has been concluded, recover from the contractor all costs, losses or damages incurred or sustained as a result of the award of the contract;
cancel the contract and claim any damages suffered by having to make less favourable arrangements after such cancellation; and
c) Independent Development Trust is hereby empowered to take such
steps as it may require verifying information submitted, including, but not limited to, the use of independent auditors or other experts.
d) If there are any changes to the information supplied on this form, I/We
will inform Independent Development Trust’s Supply Chain Management Unit immediately.
Name of Enterprise: …………………………………………….……………………… Signature of Enterprise Representative: ……………………………………………………………………………………. Address: …………………………………………………………………………………….. Telephone no: …....………………………… Date: ……………………………
………………………………………. ……………………………………..
For and on behalf of the company Date
…………………………………………………………..
Capacity of signatory (Position held in Company)
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SECTION H:
DECLARATION OF INTEREST: Item Question Yes No
H.1
Is the company or any of its directors listed on the National Treasury’s Database of Restricted Suppliers as companies or person prohibited from doing business with the public sector? (Companies or persons who are listed on this Database were informed in writing of this restriction by the Accounting Officer/Authority of the institution that imposed the restriction after the audi alteram parterm rule was applied). The Database of Restricted Suppliers now resides on the National Treasury’s website (www.treasury.gov.za) and can be accessed by clicking on its link at the bottom of the home page.
H.2
If so, furnish particulars:
H.3
Is the company or any of its directors listed on the Register for Tender Defaulters in terms of section 29 of the Prevention and Combating of Corrupt Activities Act No 12 of 2004)? The Register for Tender Defaulters can be accessed on the National Treasury’s website (www.treasury.gov.za) by clicking on its link at the bottom of the home page.
Yes No
H.4
If so, furnish particulars:
H.5
Was the company or any of its directors convicted by a court of law (including a court outside of the Republic of South Africa) for fraud or corruption during the past five years?
Yes No
H.6
If so, furnish particulars:
H.7
Was any contract between the company and any organ of state terminated during the past five years on account of failure to perform on or comply with the contract?
Yes
No
H.8
If so, furnish particulars:
H.9
Are members/employees of the company/suppliers also employees of the Independent Development Trust?
Yes
No