application for registration on the construction industry
TRANSCRIPT
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Application for Registration on the
Construction Industry Supplier (Goods
and Services) Database (CISD) Aurecon Consortium and Knight Piésold Consulting Engineers, on behalf of the South African National Roads Agency Soc Limited (SANRAL), is responsible for populating and maintaining the CISD.
The original, duly completed, registration form with accompanying documentation must be submitted to:
Direct enquiries at the various Local Offices at the dates and times as per Page 9 of this application form.
PLEASE KEEP COPIES OF THIS REGISTRATION FORM AND ALL DOCUMENTATION SUBMITTED FOR YOUR RECORDS
Name of Business
Trading Name
TARGET AREAS FOR CONTRACTORS Only registered Contractors who produce proof of active CIDB contractor grading designation, within the Targeted Areas stipulated in the table below will be included into the submission of the application forms on the database.
CIDB contractor grading designation Targeted Area
Grade 1 to 2 CE PE / SK / GB / EB / EP From within Ingquza Hill Local Municipality
Grade 3 to 5 CE PE / SK / GB / EB / EP From within Ingquza Hill Local Municipality, Port St Johns Local Municipality and Mbizana Local Municipality
Grade 6 to 7 CE / SK / GB / EB / EP From within the O R Tambo District Municipality
TARGET AREAS FOR SUPPLIERS Only suppliers registered within the Ingquza Hail Local Municipality will be included in the database.
APPLICATION FORM CHECKLIST
Y N N/A
Company Registration Document (Certified Copy)
Proof of banking in the name of the entity (Business Bank Account – original cancelled cheque or an original signed and stamped letter issued by your bank not older than three (3) months
An Original Valid Tax Clearance Certificate (TCC) or a TCC downloaded from SARS E–filing and a result summary page
VAT Registration number to appear on the TCC if VAT registered
U.I.F Registration number to appear on the TCC if registered for U.I.F
Security Officer’s Board Certificate (applicable to security services only) (Copy)
Construction Industry Development Board Certificate (CIDB) / I Tender website printout
(Copy)
National Home Builders Registration Council (NHBRC) Registration Certificate (Copy)
Professional Driving Permit (PDP) (Copy)
B-BBEE Rating Certificate (Original /Original legible Certified copy) or Sworn Affidavit (Original)
Declaration of Interest – Page 8 (Original)
Proof of Active Supplier Listing on the National Treasury Central Supplier Database (www.treasury.gov.za)
NRA N.002-200-2016/1F: N2 Wild Coast Toll Highway Section 20 between the Lingeni Intersection (km) and Msikaba Bridge (km 33.02)
NRA N.002-200-2016/3F: N2 Wild Coast Toll Highway Section 20 between the Msikaba Bridge and the Mtentu Bridge
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COMMODITIES (Please tick relevant box)
SERVICES GOODS
Civil Contractors (CIDB Registered CE) Truck and Plant Hire
Building Contractors ( CIDB Registered GB) Hardware and equipment
Other contractors (CIDB Registered EB, EP, SK etc.)
Construction Materials (eg.: cement, steel, stone, sand, water, bitumen, etc.)
Catering Fuel
Security Licensed/Permitted Hard Rock and Sand Sources (quarries, borrow pits, sand mines etc.)
Cleaning Services Professional Protective Equipment
Relevant Professional Services (Training, Building Inspectors etc.)
Accommodation
Transport (Buses, mini buses)
Other (please specify):
Certified proof of professional qualifications for specialized services eg. construction, engineering, training institute, etc. – would have to submit CIDB, NHBRC, ECSA, CESA ASATA, SACPVP, PSiRA, CETA PDP to be submitted by all transport companies as well as proof of Public Liability Insurance. Certificate of Acceptability for food premises to be submitted by all companies offering catering services. OUR CORE BUSINESS IS (Brief description)
1. COMPANY REGISTRATION DOCUMENTS
NB. DOCUMENTARY PROOF MUST BE PROVIDED WHERE APPLICABLE (Please mark N/A if not applicable.)
1.1 COMPANY TYPE (NB Documentary Proof of registration must be provided)
PUBLIC COMPANY LTD SOLE PROPRIETOR
PRIVATE COMPANY (PTY) LTD PARTNERSHIP
CO-OPERATIVE BUSINESS TRUST
CLOSE CORPORATION CC OTHER
1.2 COMPANY, CK NUMBER
Not applicable to all companies, please specify if N/A
Have you attached a Certified copy of your Company Registration document or other applicable documentation if N/A?
1.3 VERIFICATION OF BANKING
Has section 2.4 been completed (Page 5)
1.4 VAT REGISTRATION
VAT Registration No. as reflected on the Tax Clearance Certificate
1.5 TAX CLEARANCE CERTIFICATE
Income Tax Registration number as reflected on the Tax Clearance Certificate
Have you attached an original valid Tax Clearance Certificate or
a TCC downloaded from SARS E filing accompanied by result
summary page?
Tax Clearance Certificate number
1.6 UNEMPLOYMENT INSURANCE FUND (UIF)
Unemployment Insurance fund No.
1.7 SECURITY OFFICERS BOARD REGISTRATION NO. (MANDATORY, IF APPLICABLE)
Security officers board registration No Applicable to security industry only, please specify if N/A Have you attached your Security Officers Board Registration document?
1.8 CONSTRUCTION INDUSTRY DEVELOPMENT BOARD (CIDB) REGISTRATION (MANDATORY, IF APPLICABLE)
CIDB Contractors registration No. Applicable to Construction industry only, please specify if N/A Have you attached your CIDB Contractors Registration Certificate?
1.9 NATIONAL HOME BUILDERS REGISTRATION COUNCIL (NHBRC) (MANDATORY, IF APPLICABLE)
NHBRC registration No. Applicable to Building Contractors only, please specify if N/A Have you attached your NHBRC Registration Certificate?
1.10 PROFESSIONAL DRIVING PERMIT (PDP) (MANDATORY, IF APPLICABLE) Applicable to Transport Companies only, please specify if N/A EXIPRY DATE Have you attached a certified copy of your Driver’s license?
1.11 OTHER APPLICABLE PROFESSIONAL REGISTRATION CERTFICATES Eg.: Certificate of Acceptability for food premises, accommodation, etc. Have you attached your certificate?
Y N/A
Y N/A
Y N/A
Y N/A
Y N/A
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Y
Y N/A
1.12 B-BBEE RATING CERTIFICATE
Have you attached an Original Valid Certified Copy of the B-BBEE Rating Certificate/ Sworn Affidavit?
Select the relevant status below and attach the relevant document:
Large Enterprise: QSE EME
Valid, original or legible certified copy of a B-BBEE Verification Certificate issued by SANAS
A valid, original or a legible certified copy of a B-BBEE Verification Certificate issued by SANAS or A valid, original or a legible certified copy of a B-BBEE Verification Certificate issued by SANAS; or
Valid, original affidavit confirming annual
turnover and level of black ownership;
Valid, original affidavit confirming annual turnover and level of black ownership; or
CIPC affidavit
1.13 OWNERSHIP BY DISTINGUISHED GROUPING
As per your Central Supplier Database (CSD) registration, list the percentage ownership of the following groups:
Grouping Percentage (%) Ownership
> 51% Y/N
Black Women
Black Youth
Black Disabled
Black Military Veteran
Black People Living in Rural or Undeveloped Areas and/or Townships
1.14 DECLARATION OF INTEREST (Page 8) Have you completed and attached an ORIGINAL Declaration of Interest form?
1.15 CENTRAL SUPPLIER DATABASE (CSD) NUMBER Have you provided a printed copy of the Active Supplier Listing on the National Treasury Central Supplier Database (www.treasury.gov.za)?
Y N
Y N
Y N
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R R
2. BUSINESS PARTICULARS
2.1 INGQUZA HILL MUNICIPAL WARD NUMBER OFFICE IS LOCATED IN
2.2 NAME OF BUSINESS
2.2.1 Business Trading Name
2.2.2 Office Postal Address (Provide a copy of the latest municipal account. If premises are being rented, provide copy of a valid lease agreement)
2.2.3 Office Physical Address
2.2.4 Office Telephone No.
2.2.5 Office Fax No.
2.2.6 Office E-mail Address
2.2.7 Contact Person for correspondence
Title
Surname
Telephone
E-mail Address
Fax Number
Cell No.
2.2.8 Correspondence Method
All correspondence will be sent via email.
2.3 ANNUAL AVERAGE TURNOVER*
Indicate annual average turnover excluding Value Added Tax during the past three years (If applicable):
1 2 3
2.4 BANKING DETAILS (Proof of banking in the name of the entity must be provided, i.e. Business Bank Account – original cancelled cheque or an original signed and stamped letter issued by your bank not older than three (3) months)
Banking institution name
Branch
Branch Code
Town / City
Banking account number
Account holders name
Account Type
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City Code
Province
City Code
Province
Municip
al Area
First Name
R
2.5 OWNERS/SHAREHOLDERS/DIRECTORS/TRUSTEES/BENEFICIARIES
Capacity
Owners O
Shareholder S
Directors D
Trustees T
List all persons who are directors, shareholder, member, partner, trustee, sole proprietor or any persons with a right or entitlement to share in profits, revenue or assets of an entity. Please note, where a director is a shareholder, both should be confirmed. Provide Certified Identity copies of owners (members, directors, partners etc.). Multiple copies of this page may be submitted, as needed.
Name of Holding Company/Trust
Percentage owned by Holding Company or Trust
First Name
Surname
Identification Number
Percentage Share
Capacity
Gender
Race Group
Disabled
First Name
Surname
Identification Number
Percentage Share
Capacity
Gender
Race Group
Disabled
First Name
Surname
Identification Number
Percentage Share
Capacity
Gender
Race Group
Disabled
Race Group
African A
Coloured C
Indian I
White W
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Y
W I
F
Y
W I
F
%
Y
W I
F
3. PREVIOUS RELAVANT EXPERIENCE RECORD
Employer and Project Name Project type Referee Name and Tel No.
Contract price (Value of work
undertaken by the Supplier)
Contract start date
*Months to complete Works
* Where Works are still being undertaken, the proposed completion date is also to be given.
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4. DECLARATION OF TENDERER’S PAST SUPPLY CHAIN MANAGEMENT PRACTICES
Notes to tenderer: 1. This declaration:
a) must form part of all tenders submitted. b) in the case of a joint venture (JV), must be completed and submitted by each member of the JV.
2. This form serves as a declaration to be used by institutions in ensuring that when goods and services are being procured, all reasonable steps are taken to combat the abuse of the supply chain management system.
3. The tender of any tenderer may be disregarded if that tenderer or any of its directors have: a) abused the institution’s supply chain management system; b) committed fraud or any other improper conduct in relation to such system; or c) failed to perform on any previous contract.
4. In order to give effect to the above, the following questionnaire must be completed and submitted with this tender.
4.1 Is the tenderer or any of its directors listed on the National Treasury’s Database
of Restricted Suppliers as companies or persons 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 partem rule was applied. The Database of Restricted Suppliers now resides on the National Treasury website (www.treasury.gov.za) and can be accessed by clicking on its link at the bottom of the home page.
Yes
No
4.1.1 If Yes, furnish particulars:
4.2 Is the tenderer 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 website ((www.treasury.gov.za) by clicking on its link at the bottom of the home page.
Yes
No
4.2.1 If Yes, furnish particulars:
4.3 Was the tenderer or any of its directors convicted by a court of law (including a court outside the Republic of South Africa) for fraud or corruption during the past five years?
Yes
No
4.3.1 If Yes, furnish particulars:
4.4 Was any contract between the tenderer 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
4.4.1 If Yes, furnish particulars:
CERTIFICATION I, the undersigned,………………………………………………………………………………………..certify that the information furnished on this declaration form is true and correct. I accept that, in addition to cancellation of a contract, action may be taken against me should this declaration prove to be false. Signature: …………………………………………….. Name: ………………………………………………… Position: ………………………………………………… Date:………………………………………………………. Name of supplier: ………………………………………..
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5. CERTIFICATE OF CORRECTNESS OF INFORMATION SUPPLIED IN THIS DOCUMENT
I, THE UNDERSIGNED, WHO WARRANTS THAT I AM DULY AUTHORISED ON BEHALF OF THE SUPPLIER TO CERTIFY THAT THE INFORMATION SUPPLIED IN TERMS OF THIS DOCUMENTIN ITS SEMI-COMPLETE, COMPLETE AND AMENDED STATES, INCLUDING THE SUPPORTING DOCUMENTATION, IS CORRECT AND ACCURATE WITH THE DATE OF VERIFICATION DATE AS THE EFFECTIVE DATE AND ACKNOWLEDGES THAT: -
1. The supplier will be required to furnish documentary proof of the claims if requested to do so.
2. If the information supplied is found to be incorrect then the client may, in addition to any remedies it may have: -
i. Recover from the contractor all costs, losses or damages incurred or sustained by the client as a result of the award of the contract, and/or
ii. Cancel the contract and claim any damages which the client may suffer by having to make less favorable arrangements after such cancellations: and/or
iii. Impose a penalty on the contractor as provided for in the relevant organization’s regulations.
SIGNED ON THIS DAY OF 201 AT
(SIGNATURE) IN HIS /HER CAPACITY AS
(PRINT NAME)
ON BEHALF OF THE (SUPPLIER’S NAME)
IMPORTANT NOTICE
The database will be validated against the National Treasury Central Supplier Database. All service providers to ensure they remain valid at
all times.
SUBMISSION OF DATABASE FORMS
Applications are to be completed and emailed with the required documents to the following email address: [email protected] Subject of the email is to be titled as the Supplier’s Trading Name.
PUBLIC LIAISON OFFICERS (PLO’S):
Nkosiyodwa Macinwana 083 438 3805
Sala Mhlongo 073 088 9871
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