SCM-418 Title (i.e.. Prof/Dr/Mr/Me) Name Surname Identification/Passport Number Registered/Legal Name Trading Name Company Registration Number Section 1C: Tax Control Income Tax no VAT Reg No ALL CITY OF CAPE TOWN SUPPLIERS MUST BE REGISTERED ON THE CSD DATABASE To register on CSD you need to utilise their website: www.csd.gov.za or http://secure.csd.gov.za -Section 44 (Prohibition on awards to persons in the service of the state) -Section 45 (Awards to close family members of persons in the service of the state - Reporting only) Municipality may not make any award to a person. CSD Number: MAAA………………………. a. Who is in the service of the state Please indicate with a X the type of registration in selection box Central Supplier Database (CSD) Sole Proprietor (Complete Section 1 A) Registered Company as per CIPC (Complete Section 1 B) Suppliers providing false or fraudulent information shall subject themselves to immediate disqualification c. Who is an advisor or Consultant contracted with the municipality or municipal entity. b. If the person is not a natural person, of which any Director, Manager, Principal stakeholder or stakeholder is a person in the service of the state; or website : www.capetown.gov.za Supplier Management Office 2nd Floor, Civic Centre, 12 Hertzog Boulevard , Cape Town. 8000 Incomplete vendor applications will not be processed and documents will be returned without prejudice Before completing this application form be aware of Section 44 Section 45 as reflected in the Municipal Supply Chain CSD will validate and authenticate all information and provide you with a CSD reference no starting with MAAA…… (Email address for queries ONLY & NOT FOR REGISTRATION SUBMISSIONS: [email protected]Tel: +27 21 400 4200 / 3721 / 1044 / 9244 / 1045 / 5510 / 5509 Fax : +27 21 400 2018 PC Fax : 086 546 1881 City of Cape Town may not transact with anybody in the service of the state. Version: 15 Supplier Registration Form Approved by Branch Manager As per CIPC document The detail as shown on your Tax Clearance Certificate Full name(s) as per ID/Passport The detail as shown on your Tax Clearance Certificate Section 1 A: General Details for Sole Proprietor Section 1 B: General Details for Registered Company (As per CIPC document) Page 1 of 5
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SCM-418
Title (i.e.. Prof/Dr/Mr/Me)
Name
Surname
Identification/Passport Number
Registered/Legal Name
Trading Name
Company Registration Number
Section 1C: Tax Control
Income Tax no
VAT Reg No
ALL CITY OF CAPE TOWN SUPPLIERS MUST BE REGISTERED ON THE CSD DATABASE
To register on CSD you need to utilise their website: www.csd.gov.za or http://secure.csd.gov.za
-Section 44 (Prohibition on awards to persons in the service of the state)-Section 45 (Awards to close family members of persons in the service of the state - Reporting only)Municipality may not make any award to a person.
CSD Number: MAAA……………………….
a. Who is in the service of the state
Please indicate with a X the type of registration in selection box
Central Supplier Database (CSD)
Sole Proprietor (Complete Section 1 A)
Registered Company as per CIPC (Complete Section 1 B)
Suppliers providing false or fraudulent information shall subject themselves to immediate disqualification c. Who is an advisor or Consultant contracted with the municipality or municipal entity.
b. If the person is not a natural person, of which any Director, Manager, Principal stakeholder or stakeholder is a person in the service of the state; or
Incomplete vendor applications will not be processed and documents will be returned without prejudice
Before completing this application form be aware of Section 44 Section 45 as reflected in the Municipal Supply Chain
CSD will validate and authenticate all information and provide you with a CSD reference no starting with MAAA……
(Email address for queries ONLY & NOT FOR REGISTRATION SUBMISSIONS: [email protected]: +27 21 400 4200 / 3721 / 1044 / 9244 / 1045 / 5510 / 5509 Fax: +27 21 400 2018 PC Fax: 086 546 1881
City of Cape Town may not transact with anybody in the service of the state.
Version: 15
Supplier Registration FormApproved by Branch Manager
As per CIPC document
The detail as shown on your Tax Clearance Certificate
Full name(s) as per ID/Passport
The detail as shown on your Tax Clearance Certificate
Section 1 A: General Details for Sole Proprietor
Section 1 B: General Details for Registered Company (As per CIPC document)
Page 1 of 5
Street Name and No
City Country
Postal Code
PO Box Number City
PO Box Postal Code Country
Postnet Suite no
Private Bag
Postal Code
Name Name
Telephone number: Telephone number
Cell phone number: Cell phone number
Fax number for orders Fax no for Remit
E-mail address for orders and
general communications
E-mail address for payment
remittances
Website Address
Bank Name Branch Code
Account Number
Cheque Account 01
Savings/Transmission Account 02
Proof of Bank Account
Please include the following Supporting Documentation
Section 4: Banking Details
Section 2: General Address Details
Company Accounts Clerk
Region: eg:
E-Cape, W-Cape
Section 3: Contact Details
Company Representative for Sales and Orders
Proof of authorised Signatories on account:
Account Holder
Letter from bank indicating authorised list of approved
name(s) and Identification number(s)
Copy of Bank Statement
Page 2 of 5
Level % Points
B-BBEE level of contribution (Turnover Above R10 Million)
Exempt Micro Enterprise level of contribution (EME)
(Turnover Below R10 Million)
% Black Woman Ownership %
% Black Ownership %
NO YES
NO YES
NO YES
Are you a cooperative which is at least 51% owned by black people NO YES
NOTE:
Expiry Date
Expiry Date
Expiry DateIssue Date
Expiry Date
Expiry Date
Expiry Date
SARS verification PIN no
Are you an EME or QSE which is at least 51%owned by black people who are youth
Occupational Health and Safety Act (OHSA)
Non Profit Organisation (NPO)
Non Governmental Organisation(NGO)
Any other related body linked to a certificate
OHSA Certificate Number
If YES, attached certificate.
Section 5: B-BBEE Classification Data
Are you an EME or QSE which is 51%owned by black people living in rural or underdeveloped areas
Department of Agriculture Certificate Number
CIDB : CR Number
Department of Agriculture Certificate
Section 6: Various Certificates
Are you an EME or QSE which is at least 51%owned by black people who are military veterans
COIDA Certificate
Construction Industry Development Board
Tax Clearance Certificate No
The detail as shown on your Letter of accreditation
Tax Clearance Certificate
ALL vendors are required to submit one of the following in order to qualify for preference points:• Companies with a turnover less than R10 Million per annum quali�es as an Exempted Micro-Enterprise and must submit a a�davit /certi�cate issued by either verification agencies accredited by the SANAS or by registered auditors approved by the IRBA (http://www.irba.co.za/index.php/b-bbee-verification-assurance)• Companies with a turnover above R10 Million per annum must submit a rating certi�cate issued by a SANAS approved agency or registered auditors approved by the IRBA (http://sanas.co.za/af-directory/bbbee_list.php)• ALL Certi�cates must display the SANAS logo / Registered Auditors IRBA B-BBEE Number
Security Industry Regulation Act (SIRA)
If YES, attached certificate.
If YES, attached certificate.
The detail as shown on your valid B-BBEE Certificate
SIRA Certificate Number
Compensation of Industry on Duty Act
Yes No
Yes No
Yes No
NoYes
No
Yes No
Yes No
Yes No
Yes
Yes No
Page 3 of 5
Maximum of five industry keys
1
2
3
4
5
Refer to ANNEXURE B, list of codes available on our Website grouped with the registration documentation at
Proof of Banking(Copy of Statement or Cheque & Letter to state the list of signatories) -------------------------
Certified Copy of Identity Document of All owners, partners or members in your company -------------------
Copy of Tax Clearance Certificate & page that indicates SARS pin no information-----------------------------
Construction Industry Development Board Certificate(CIDB) --------------------------------------------------------
Number
Example: 1640 Advisory Services - Accountants and Auditing
Proof of Company Registration Documents(CIPC)---------------------------------------------------------------------
Proof of Black Women Equity Ownership -------------------------------------------------------------------------------
Please specify the commodities and/or type of services you provide (MAXIMUM OF FIVE)
Page 4 of 5
Section 9: Declaration of Interests
Please note: After the completion of this application document and you have obtained
your City of Cape Town Supplier No, it remains the responsibility of the Supplier to keep
the City of Cape Town informed of any changes of their Supplier Data
1. (Print Name) (Signature)
SIGNED AT ..................................................................... THIS.............DAY OF ....................................20.........
THE APPLICANT
I, the undersigned who warrants that I am duly authorised to do so on behalf of the business, confirms that the contents of
this Affidavit are within my personal knowledge to the best of my belief both true and correct.
I hereby agree that in the event of false, incorrect or misleading information being provided in this declaration, City of
Cape Town shall have the right to:
- Recover any losses or damages sustained by City of Cape Town Works under such agreement
- Restrict the supplier from further business with City of Cape Town depending on the materiality of the misinterpretation
and the degree of the prejudice suffered.
Name …………………………………………………………………………
Identity No. …………………………………………………………………………..
Signature: …………..…………………………………………(Duly authorised to sign for and on behalf of the above entity)
Date: ……………………… Telephone: …..………………………………..
Commissioner of Oath:
Signed and sworn before me at..................................................................(place) this the ………………(day)of
(month)………………………………………(year)______ by the above mentioned who acknowledges that he/she knows
and understands the contents of this Affidavit and that it is true and correct to the best of his/her knowledge and that
he/she has no objection to taking the prescribed oath will be binding on his/her conscience.
Commissioner of Oaths signature…….………………………………………..
Print name………………………………………………………………………...
Date………………………………
Commissioner of Oath stamp:
The attached Declaration of Interest (Annexure A) must be completed and signed. (COMPULSORY).
If there is any known potential conflict of interest or if any owner, partner or member of the applicant is an official, an employee or a councillor
of the City of Cape Town, or is related to an official, an employee or a councillor of the City of Cape Town, that relationship must be indicated
in the Declaration of interest.
Section 10: Affidavit
The affidavit must be completed and signed(compulsory).
Page 5 of 5
1
ANNEXURE A Declarations: Supplier Application
SUPPLY CHAIN MANAGEMENT: SUPPLIER MANAGEMENT
SCM – 555 B Approved by Branch Manager: 19/08/2014 Version: 4 Page 1 of 6
Company Name
Company Legal Name
Supplier Number
(If already registered)
SCHEDULE A: DECLARATION OF INTEREST – STATE EMPLOYEES
1. No bid will be accepted from persons in the service of the state¹.
2. Any person, having a kinship with persons in the service of the state, including a blood
relationship, may make an offer or offers in terms of this invitation to bid. In view of possible
allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons
connected with or related to persons in service of the state, it is required that the bidder or
their authorised representative declare their position in relation to the
evaluating/adjudicating authority.
3 In order to give effect to the above, the following questionnaire must be completed and
submitted with the bid.
3.1 Full Name of applicant or his or her representative:……………………………………………..