questionnaire for supplies - goods (2)
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SUPPLIER DATABASE
REGISTRATION
QUESTIONNAIRE SUPPLIES - GOODS
Name of company
Town / City
IDT Internal Staff
Submitted by .Ext..
The supplier will be used for: (please mark with a tick)
Programmes ( ) or
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Overheads ...( )
All supplier information will be treated strictly confidential.
ALL SUPPLIER INFORMATION WILL BE TREATED STRICTLYCONFIDENTIAL.
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 stamped letter from the bank, verifyingthe banking details.
2. Copy of Company Registration documents.3. 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 IDTs
definition (see below) to submit copies of the following:
Close Corporations to attach an Association Agreement(Pty) Ltds to attach Shareholders Agreement, Memorandum of Association aswell as share certificates
The above documents to stipulate management responsibilities, profitsharing, liabilities/responsibilities, management contribution, protection incase of death etc.
Letter from the Bank stating all signatories8. Copy of COIDA (Compensation for Occupational Injuries and Diseases)
registration certificate e.g. Letter of Good Standing.
BLACK ENTERPRISES
The following is a guide on how Independent Development Trust definesBlack Enterprise Companies:
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Definition: Black means South African citizens who are Black, Indian orColoured persons and EXCLUDES individuals belonging to such communitiesfrom any other country.
Black Women-owned Enterprises (BWO):
At least 50% of the voting shares or interests are held and controlled byBlack 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 orinterest just to capture or retain contracts, and
Black Women participate in the day to day management and decisionmaking of the enterprise. They necessarily have the aptitude andpotential to understand all issues involved in the running of theenterprise including knowledge of the product and market within whichtheir enterprise operates.In a joint venture, skill must be transferable to the Black Womenentrepreneur, which means that the Black Women entrepreneur musthave 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 ofbusiness:_________________________________________________________
(Contracts/order will be placed on this name and invoices must reflect it)
Previous name of the business (if applicable)______________________________________________
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 torender sevices 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:________________________
Contact person fax number: Code: _______Number_________________________(Will be used by IDT for electronic faxing of Request for Services,Contracts and Purchase Orders)
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Business e-mail:____________________________________________________________________
Your own business contact person/marketing representative name andtelephone number:
__________________________________________________________________________________
Business registration number (if applicable)
_______________________________________________(In case of sole proprietor, please furnish identity number plus certifiedcopy of identity documents)
Tax number of business: (if applicable)
_________________________________________________
VAT Registration number: (if applicable)_________________________________________________
A2. BANK INFORMATION:
Please attach an original cancelled cheque or an original bank verification
letter.
Bank: ___________________________________ Branch code:
_______________________
Branch Location:
_____________________________________________________________
Account Holder:
_____________________________________________________________
Bank Account number: __________________________ Account type:
__________________
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 furnished)
SECTION B:EMPOWERMENT
1. EMPLOYMENT EQUITY
B2.PERCENTAGE OF TOTAL SHARES OWNED BY EACH OF THE FOLLOWING
GROUPS (Attach shareholders Certificate)
% Black % Asian % Coloured % White
% % % %
% Black Female % Asian Female % Coloured Female % White Female
% % % %
% Black Disabled % Asian Disabled % Coloured Disabled% WhiteDisabled
% % % %
B1. MANAGEMENT STRUCTURE
(Percentage of management on executive level in each of the following groups)
% Black % Asian % Coloured % White
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B3. LIST OF ALL PARTNERS, PROPRIETORS ANDSHAREHOLDERS.
(Re (Attach shareholders Certificate)
B4.COMPLETE THE FOLLOWING INFORMATION FOR EACH PARTNER,
PROPRIETOR, SHAREHOLDER, DIRECTOR AND OFFICER OF THEFIRM
(eg Chairman, Secretary, Director, etc)
Name RaceGender
M/F
Disabled
Yes/No
% of timedevotedto firm
Home Address
(PLEASE ATTACH THE COMPANYS EMPLOYMENT EQUITY TARGETFOR NEXT FIVE YEARS)
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B5. WHAT IS THE FIRMS AVERAGE ANNUAL TURNOVER (EXCLUDING VAT)?
R. _____________
B6.
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 ANDBUSINESS DECISIONS
Activity Name RaceGender
M/F
Disabled
Yes/No
Lengthof
Service(Years)
Financial Decisions
Cheque Signing
Acquisition of LinesCredit
Sureties
Major Purchase orAcquisitions
Signing Contracts
Management Decisions
Costing
Marketing and SalesOperations
Hiring and firing ofManagementPersonnel
Supervision ofOfficePersonnel
Supervision ofField /ProductionActivities 8
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B7. TOTAL NUMBER OF EMPLOYEES?
Full time
Part time
B8. LOCALITY
PLEASE INDICATE WITH (X) AREAS WHERE YOUR BUSINESS CURRENTLYOPERATES/ AREAS OF REPRESENTATION:
Region Description HO Branch Rep
EC Eastern Cape
FS Free State
GP Gauteng
KZN KwazuluNatal
MP Mpumalanga
NC NorthernCape
NW North West
L Limpopo
WC Western Cape
Kindly indicate: Head Office, Branch Office (s) and where represented only.
Physical address: . Physical address:
...............
... ... ...
Tel no:.. Tel no:
..
Fax no:. Fax no:
.
PO Box/Private Bag... PO Box/Private
Bag...
City:.. City:
..
Code: Code:
Registered Professional name Registered Professional
name..
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Physical address: . Physical address:
..............
.
... ... ...
Tel no:.. Tel no:
..
Fax no:. Fax no:
.
PO Box/Private Bag... PO Box/Private
Bag...
City:.. City:
..
Code: Code:
Registered Professional name Registered Professional
name
Attach list if space provided is inadequate
Is your business:
An agent ______________________________________
Manufacturer___________________________________
Distributor Consultant_____________________________
SECTION C:CAPACITY
1. CAPACITY AND PAST PERFORMANCE
C1.LIST THE THREE LARGEST PROJECTS COMPLETED BY YOUR FIRM IN THE
LAST FOUR YEARS
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Name of ProjectCompleted
Name of ProjectManager
&Telephone no.
Name of Client &Telephone no. Value of Project
C2. LIST THE CURRENT PROJECTS THAT YOUR FIRM IS INVOLVED IN
Name of CurrentProject
Name of ProjectManager &
Telephone no.
Name of Client &Telephone no.
Value of Project
C3. PREVIOUS APPOINTMENTS BY IDT
Project/ProgrammeName
Type of project Contractperiod
ContractValue
Financialyear
IDT ContactPerson & Tel no.
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C4. DID THE FIRM EXIST UNDER A PREVIOUS NAME? YES/ NO
IF YES, WHAT WAS THE NAME:______________________________________________
C4.1 WHO WERE OWNERS/ PARTNERS/ DIRECTORS:
TECHNICAL
C5.IS YOUR BUSINESS A PERMIT HOLDER UNDER THE SABS, MARKSCHEME? (Y / N )
.
IF YES, INDICATE PRODUCT(S) FOR WHICH PERMITS ARE HELD,INCLUDING PERMIT
NUMBERS
QUALITY
C6. HAS YOUR QUALITY MANAGEMENT SYSTEM BEEN ASSESSED &CERTIFIED BY ANY NATIONAL / INTERNATIONALLYRECOGNISED ACCREDITED BODY (Y / N ) IF YES PROVIDE COPYOF CERTIFICATE.
1.TYPE OF BUSINESS
D1. TYPE OF FIRM (Tick applicable box)
Joint Venture
Partnership
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Company
Close Corporation
One Person Business / Sole Trader
Other
D2. Human Resources
1. Briefly state your Affirmative Action (AA) Policy.
D3. Proudly South African
Do you get more than 80% of your material from your Local Area
Geographically : Yes ______________________ No ______________________
PlaceNationally : Yes_______________________ No_______________________
Region
Internationally : Yes_______________________ No_______________________
Country
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SECTION E:
ATTACHMENTS (COMPULSORY)
Please attach certified copies/original of the following documents: Tick
Fully Completed Supplier Questionnaire
Cancelled cheque or an original bank verification letter
ID Documents of owners
Company Registration Documents
D4. SAFETY (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 for Occupational Injuries and DiseasesAct (COIDA) Yes/No
COIDA registration number_________________________________
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Shareholders agreements / certificates for companies
claiming Black Economic Empowerment
VAT certificate (if a VAT vendor)
Valid Tax clearance certificate
JVS Agreement (if a joint venture)
SWORN STATEMENT
I/we, the undersigned, who warrant that I/we am/are duly, authorised to do so,on behalf of the enterprise, certify that:
a) The information furnished is true and correct.
b) If misrepresentation to gain any benefit is established, IndependentDevelopment Trust may in addition to any other remedy it may have
disqualify the applicant;
restrict the applicant, its shareholders and directors fromobtaining business from Independent Development Trust for aperiod not exceeding 5 years;
in the event that a contract has been concluded, recover fromthe 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 suchsteps as it may require to verify information submitted, including, butnot limited to, the use of independent auditors or other experts.
d) If there are any changes to the information supplied on this form, I/Wewill inform Independent Development Trusts Supply ChainManagement Unit immediately.
(INCOMPLETE SUBMISSIONS WILL NOT BE PROCESSED. THISINCLUDES THE SUPPORTING DOCUMENTATION AS STIPULATED)
Name of Enterprise:.
Signature of Enterprise Representative:
.
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Address..Telephone no: ....Date:
--------------------------------------------------------------------- ---------------------
For and on behalf of the company Date
--------------------------------------------------------------------------------
Capacity of signatory (Position held in Company)
FOR IDT USE ONLY:
1. Supplier Approval:
Procurement Department: ______________ Date __________
Senior Supply Chain: ______________________ Date______________
Information captured on IDT supplier database:
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by (name)_____________________________ Date _____________
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