MNQUMA LOCAL MUNICIPALITY

CONTRACTORS DATABASE

APPLICATION FORM FOR THE FINANCIAL YEAR 2014/2015

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APPLICATION FORM FOR CONTRACTORS TO BE INCLUDED ON THE MNQUMA LOCAL MUNICIPALITY CONTRACTORS DATABASE.

Please note: This form must be completed by all applicants wishing to register as a contractor with the

Mnquma Local Municipality. Please reflect all the resources the firm has such as: Plant,

Machinery, Equipment and Labour. Also reflect the expertise and experience that the company

has other relevant additional documentation may also be attached. The Municipality will

determine the suitability of firms for entry into its database, based on the information provided.

All sections of the application form must be completed in full.

The application form is to be completed by the duly authorised official of the contracting firm.

Please indicate on the space below, if this is a new application and/or update application.

New application/Update application:

Date of application: /_ / .

Once the application is completed return by Hand delivery to:

The Supply Chain Management Unity Mnquma Main Building

Cnr King & Mthatha Street, Office No.16, Butterworth

Or

Att: Supply Chain Management Unit Mnquma Local Municipality

P. O. Box 36

Butterworth

4960 Tel: 047 401 2400

NB: FAXED AND/OR EMAILED APPLICATION WILL NOT BE ACCEPTED!

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PARTICULARS OF FIRM

1. Name of Firm:

2. Name of the Managing Director:

3. Type of firm (tick relevant box)

Partnership

One person business/sole proprietor

Close corporation

Company

[Pty] Limited

Consortium

Other (specify)

4. Co./CC Registration Number:

5. Vat. Registration Number:

6. Tax reference number:

NB: Insert personal income tax reference number if one-man business and personal

income tax reference numbers of all parties if a partnership.

7. Membership with professional bodies:

[include membership number]_

8. B-BBEE Verification Status Level

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PREREQUISITES: NOTE: CONTRACTORS WILL NOT BE REGISTERED ON THE DATABASE IF THE FOLLOWING PREREQUISITES ARE NOT MET.

1. Proof of company registration and/or any other form of legal standing must be

submitted

2. A current and original Tax Clearance certificate from South African Receiver of

Revenue Service [SARS] certifying that the taxes of the applicant are in order or that

suitable arrangements have been made with SARS to bring them in order. The Tax

Certificate will be reworded at the allocated space for the VAT number with the words

“compulsory if turnover is more than R300 000”. Where the person is not required to

be registered for VAT, the Receiver of Revenue will write “not required to register”

next to the allocated space for the VAT registration number.

3. Submit proof of Professional Registration with the relevant Professional Body e.g

CIDB Certificate.

4. Submit Company composition on the form attached as Annexure “H”.

5. Complete Annexure “C1”, “C2”, and “D”.

6. Attach Board - Based Black Economic Empowerment (B-BBEE)

Strategy/Transformation Strategies/ strategies to empower the Disabled/physically

challenged.

7. Proof of Registration with the commissioner for compensation (Workman’s

Compensation).

8. Submit a copy of the South African Identity Document.

9. Submit a copy of a company profile.

10. Submit of Letter from the bank confirming banking details and/or cancelled cheque

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CONTACT DETAILS

1. Contact person:

Phone No.:

Cell No.:

Fax No.:

E-Mail:

2. Postal Address:

3.

Physical Address:

Postal Code

Postal Code_

4. Eastern Cape Offices: _

5. National Offices:

CONTRACTORS MUST INDICATE WHAT CATEGORY OR SIZE OF WORK THEY ARE ABLE TO UNDERTAKE:

Micro Projects R0 – R120 000

Small Size Projects R120, 000 – R500, 000

Medium Sized Projects R500, 000 – R1 Million

Large Projects Above R1 Million

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PLEASE INDICATE THE FIELD OF COMPETENCE YOUR FIRM WILL BE REGISTERING FOR, BY TICKING IN THE BOX: (PROFESSIONAL SERVICE PROVIDERS ONLY)

Road

Tar

Building

Electricity

Wet Services (Plumbing & granadge)

Welding

Specify if other:………………………………………………………………………………………..

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

More than one (1) field of competence may be selected.

Engineering and Construction Plant Hires

Grader 13 tons or more articulating or ridged,

4 X4 Tow Tractor with Grid Roller (not less 13 tons,

Water tanker minimum 8000 with sprayers for road construction with

Capacity to load and discharge pressurized water,

Tracked Excavator minim 18 tonnes fitted with rock bucket,

Tipper trucks 10 M₃s,

Dozer D6 or its equivalent,

4X4 LTB,

8 tone train truck

Skip louder truck

Lobed

Concrete Cutter

Concrete mixer

Grid Roller

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ANNEXURE C.1

PPAASSTT EEXXPPEERRIIEENNCCEE ((OOTTHHEERR IINNSSTTIITTUUTTIIOONNSS EEXXCCLLUUDDIINNGG MMNNQQUUMMAA LLOOCCAALL

MMUUNNIICCIIPPAALLIITTYY))

Contractors must furnish hereunder details of similar works/service, which they have

satisfactorily completed in the past. The information shall include a description of the Works, the

Contract value and name of Employer.

EMPLOYER

NATURE OF WORK

VALUE OF WORK DURATION AND

COMPLETION DATE

EMPLOYER CONTACT NO.

Supply additional annexures if the above is not adequate

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AANNNNEEXXUURREE CC..22

PPAASSTT EEXXPPEERRIIEENNCCEE ((MMNNQQUUMMAA LLOOCCAALL MMUUNNIICCIIPPAALLIITTYY OONNLLYY))

Contractors must furnish hereunder details of similar works/service, which they have

satisfactorily completed in the past for Mnquma Local Municipality. The information shall

include a description of the Works, the Contract value and name of Employer.

PREVIOUS AND/OR CURRENT PROJECTS UNDERTAKEN FOR MNQUMA MUNICIPALITY

PROJECT NAME

AWARDED AMOUNT

CONTRACT START

DATE

ANTICIPATED / ACTUAL

COMPLETION DATE

Supply additional annexures if the above is not adequate

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AANNNNEEXXUURREE DD

CCOOMMPPAANNYY DDEETTAAIILLSS

The following company details schedule must be completed in full. Attach a copy of Founding Statement/ Business Registration.

Registered Company Name: .....................................................................................

.............................................................................................................................

Company Registration Number: ...............................................................................

VAT Number: .........................................................................................................

Bank institution:………………………………………………………………………………………………………

Branch Name: ........................................................................................................

Bank Account Number: ...........................................................................................

Type of Account:……………………………………………………………………………………………………...

Professional Registration Details: .............................................................................

.............................................................................................................................

.............................................................................................................................

.............................................................................................................................

............................................................................................................................

. Professional Indemnity Details:

................................................................................

.............................................................................................................................

.............................................................................................................................

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AANNNNEEXXUURREE HH

CCOOMMPPAANNYY CCOOMMPPOOSSIITTIIOONN

GENERAL

All information must be filled in spaces provided. If additional space is required, additional

sheets may be attached. The onus is on the Contractors to fill in all the information. Failure to

do so will result in points being lost under equity. The full company composition is required

including HDI and Non-HDI status. The ownership must accumulate to 100%.

NAME

IDENTITY NUMBER

CITIZE NSHIP

B-BBEE STATUS

VERIFICATI ON LEVEL

DATE OF OWNERSHIP

%

OW

NE

D

%

VO

TIN

G

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AANNNNEEXXUURREE KK SSOOCCIIAALL

RREESSPPOONNSSIIBBIILLIITTYY

SOCIAL RESPONSIBILITY

BURSARIES AND MENTORSHIP PROGRAMMES PROVIDED BY COMPANY

NAME OF INCUMBENT

TERTIARY INSTITUTION

WHERE STUDIES ARE BEING

CONDUCTED

AMOUNT

ALLOCATED FOR STUDIES

MENTORSHIP PROGRAMME THAT THE INCUMBENT HAS

BEEN PLACED ON

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AANNNNEEXXUURREE FF DDEECCLLAARRAATTIIOONN

OOFF IINNTTEERREESSTTSS

Any legal person, including persons employed by the Municipality, or persons who act on behalf

of the Mnquma Local Municipality or persons having a kinship with persons employed by the

Municipality including a blood relationship, may make an application in terms of this system. In

view of possible allegations of favouritism, should the resulting application or part thereof, be

awarded to persons employed by the Mnquma Local Municipality, or to the persons who act on

behalf of the Mnquma Local Municipality, or persons connected with or related to them, it is

required that the applicant or his/her authorized representative shall declare his position vis-à-vis

the evaluating authority and/or take an oath declaring his/her interest, where –

- the applicant is employed by the Mnquma Local Municipality or acts on behalf of the

Mnquma Local Municipality; and/or

- the legal person on who’s behalf the application is signed, has a relationship with

persons/a person who are/is involved with the evaluation of the submissions, or where it

is known that such a relationship exists between the person or persons for or on who’s

behalf the declarer acts and persons who are involved with the evaluation of the

submissions.

- where the person is employed by any organ of State.

In order to give effect to the above, the following questionnaire shall be completed and

submitted with the applicant.

Are you or any person connected with the applicant, employed by the Mnquma local

Municipality?

Yes/No

If so, state

particulars:

Do you, or any person connected with the applicant, have any relationship (family, friend, other)

with a person employed with the Mnquma Local Municipality or its Administration and who may

be involved with the evaluation, preparation and/or adjudication of these submissions?

Yes/No

If so, state

particulars:

Are you or any other person connected with the applications, employed by any organ of State?

Yes/No

If so, state particulars: .

I a Principal/Director/Manager/Member of the

company called

declare

that I that I am employed (either full time or part time) by the company applying for

the registration on the database and the information furnished, as well as a the

documents submitted in support of the registration, is true and correct in every

respect ; and have been lawfully obtained; the declaration is signed on the

the day of

.

on 20 at

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