Enquiries: Ms S.
Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
Database
Registration number
SUPPLIER DATABASE REGISTRATION FORM
2024/2025
PLEASE FILL IN THE INFORMATION
Registered business
name:
Contact person:
Contact
number:
CSD
NUMBER
FOR OFFICE USE ONLY
Date received: ___________________________________________________________________________
Received by: ____________________________________________________________________________
Supplier registration number: ______________________________________________________________
Captured by: ______________________________________________________
Stamp :
Checked by: Database capture
Signature : ____________________________
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
POINTS TO REMEMBER
COMPLETING THE MKLM SUPPLIER DATABASE REGISTRATION FORM
• Completion of Questions – Clearly state Yes, No or N/A to questions asked. Do not leave any fields
blank.
• Certified Documents – Please ensure that a Commissioner of Oaths has certified your Company
Registration Document,
• Shareholding Certificates, VAT Registration, PAYE, UIF, Workman’s Compensation, Security
Officers Board Certificate (if applicable).
• Owners, Shareholders – Please ensure that the percentages of ownership of the individual
shareholders amount to 100%.
Proof of the individual shareholding is to be submitted.
• Declaration of interest form (MBD 4) is attached, kindly ensure that it is fully completed, signed and
submitted with the forms.
These forms must be completed and submitted to:
Postal Address Residential Address
Moses Kotane Local Municipality Stand no 933
Private bag X1011 Railway Road
Mogwase Unit 3
0314 Mogwase
For attention: Manager: Demand and Acquisition
Direct enquiries to the Moses Kotane Local Municipality Budget and Treasury Department: Supply
Chain Management Office
Tel: (014) 555 1313/1463/1391/1437
Registered Business Name
Trading Name
Registration no.
Y N N/A
Company Registration Document (Certified)
Proof of Ownership / Shareholder certificate (Certified)
Municipal Rates and Taxes /Proof of residence
Proof of Banking Document
VAT Registration Document
Security Officer’s Board Certificate
Disability Documents
Tax Clearance Certificate/ Tax pin
Proof of identity CERTIFIED
(owner/directors/members
NB: Please note: Proof of documents for all of the above are required to ensure successful registration on the supplier database. In
the event of a document not being required please tick the No or N/A box.
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
ABBREVIATIONS
MKLM – Moses Kotane Local Municipality
SARS – South Africa Revenue Service
CIDB – Construction Industry Development Board
BBE – Black Economic Empowerment
VAT – Value Added tax
UIF – Unemployment Insurance Fund
CSD- Central Supplier Database
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
LIST OF RETURNABLE DOCUMENTS
DOCUMENTS REQUIRED WHERE TO GET THE DOCUMENTS?
Company registration Certificates (Certified Register of close corporations &
copies ) Companies
Proof of ownership (Certified copies) Register of close corporations &
Companies
Municipal Rates and taxes clearance Relevant municipality
certificates)/proof of residence
Proof of banking Branch of bank where account is
held
Income Tax Receiver of revenue ( SARS)
Tax Clearance Certificate Receiver of revenue ( SARS)
Vat registration Receiver of revenue ( SARS)
CIDB Grading Certificate Construction of industry
Certified ID copy (owner/ directors) Home Affairs
CSD Report Central suppliers database
www.csd.gov.za
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
1. BUSINESS PARTICULARS
1.1. Registered business name
1.2. Business trading name
1.3. Business Postal Address
Code
1.4. Business Physical Address
Code
1.5. Phone number
1.6. Fax Number
1.7. Email address
1.8. Contact person for correspondence
Title First name
Surname
Cell no.
1.9. Is the company currently classified as a black economic empowerment (BEE) Y N
company?
1.10. Correspondence method
Please select your preferred method of correspondence. All correspondence will be sent using the method
you selected below.
P= Post F= Fax E = email
P E F
Correspondence
address
City Code
Province
Fax number
Email address
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
2. ANNUAL AVERAGE TURNOVER
Indicate the average annual turnover excluding value added tax during the past three years.
R…………………………………….
3. FINANCIAL DETAILS (BANKING)
Bank institution name
Branch name
Banking account no.
Account type
Account holder’s name
NB: documentary proof of banking details must be supplied (copy of cancelled cheque or bank statement.
4. STAFFING / EMPLOYEES
How many permanent staff are employed by the company over last Full time
twelve months Part time
How many staff members has joint the company in the last six months Full time
Part time
5. REGISTRATION NUMBERS
Y N Number
Enterprise registration
Income tax / SARS
Vat
UIF
CIDB ( if applicable)
6. DETAIL ALL TRADE ASSOCIATIONS/ PROFESSIONAL BODIES / BUSINESS ASSOCIATIONS
DATE NAME REFERENCE NUMBER
7. CIDB GRADING INFORMATION
CLASS OF WORK GRADE ANNUAL TURNOVER
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
8. CORE BUSINESS OPERATION
Mark with X in applicable fields
Prime Contractor Sub-contractor (less than Labour only contractor
25% generated turnover
Supplier Legal Entity
Manufacturer
Professional service Education, Training and
Other
built development service providers
Other,
Specify: ____________________________________________________________________________
Please indicate the nature of the operations, products or services to your business by ticking the
appropriate box/boxes:
9. CATEGORIES OF GOODS AND SERVICES ( SELECT ONLY FOUR (4) PRODUCTS)
Mark
with
X
1 Furniture , office design, interior decorating, art work
2 Advertising, publication and market research, promotion and printing services
3 Cleaning equipment, supplies, cleaning chemicals, disinfecting and similar services
4 Catering , accommodation and entertainment services
5 Material textile, (overalls, uniforms, shoes, etc.) and protective clothing and foot wear
6 Mail services, courier services
7 Event management, business professionals, administrative services
8 Financial, insurance services, auditing, performance audits and business services
9 Education, training services, recruitment, counselling
10 Information technology, telecommunications, hardware, software, networks, maintenance
11 Legal services
12 Faxes, photocopiers, photographic, audio, visual, electronic equipment and maintenance
13 Maintenance services for the building industry
14 Security, safety services, etc.
15 Stationary, paper, printing, books and publishing
16 Travel agencies, lodging, air travel, accommodation, car rentals
17 Consultants
18 Pipes, fittings, galvanised PVC, uPVC, mPVC, Polyethylene for all types and sizes including
19 Water meters
20 Machinery and accessories for building and construction
21 Industrial manufacturing, processing machinery, accessories
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
22 Service industry, machinery, equipment, supplies, accessories
23 Power generation, distribution machinery, accessories, etc.
24 Electrical distribution, maintenance, installation material and goods including transformers, sub
25 station, meters, etc.
26 Building material (bricks, paint, stone, sand, cement, fencing material, etc.)
27 Fuels, fuel additives, lubricants, anti-corrosive materials and gas
28 Tyres, tubes, batteries and parts
29 Fire protection equipment and materials and maintenance
30 Office equipment, accessories, supplies
31 Editorial, design, graphic, fine arts services
32 Rubber-, foam-, timber-, steel-, glass products
33 Tools and general machinery and hardware products
34 Prefabricated products (cement, fibre, cast iron, plastic, timber, steel, etc.)
35 Laboratory, measuring, testing, observing equipment and services
36 Medical equipment, accessories, supplies
37 Healthcare services (medical, dental and other health and veterinary services)
38 Drugs, pharmaceutical products
39 Domestic and industrial appliances, supplies, etc.
40 Vehicles, equipment and machinery including maintenance and repairs thereto
41 Cleaning Services
42 Water-chemicals and wastewater treatment
43 Chemicals for weed and pest control, exterminating, fumigating and similar services
44 Law enforcement, security, safety equipment, supplies
45 Structure, building, construction, manufacturing component and material
46 Professional engineering services (consulting and constructional engineers), technology based
47 General supply
48 Sports, recreational equipment, accessories, supplies
49 Environmental services and waste management
50 Plants, compost and nursery accessories
51 Vehicle towing services, vehicle storage
52 Hiring of equipment, machinery and trucks
53 Auctioneering services
54 Civil, building, electrical, mechanical contractors
55 Funeral undertaking services (undertakers and crematoriums)
56 Road building materials
57 Disaster material including emergency tents and blankets
58 Cell phones and vouchers
59 Groceries and other foodstuff
60 Repair, installation, supply and maintenance services for mechanical equipment electrical
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
61 switchgear and electronic switchgear
62 Air-conditioning, Ventilation, Fans (Repairs and maintenance)
63 Animal Feed
64 Carpets, curtains, blinds and soft furnishing
65 Containers and packaging
66 Locksmith (Locks, latches and hinges)
67 Real estate, property leasing and services
68 Radio communication and equipment
69 Removal Services (Furniture)
70 Signs, name plates and number plates
71 Refuse bags, bins and plastics
72 Banks and financial institutions
73 Florists
74 Hire, leasing services (Vehicles, office equipment, telephone systems)
75 Transport and shuttle services
76 Gardening services
77 Plumbing
Other:
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………
(Please provide brief description of goods / service provided)
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
10. BUSINESS CLASSIFICATION
In order to be identified / sourced as a potential service provider, your business needs to be
classified correctly.
Tick the correct block (X) to indicate the correct classification of your company as a service provider.
Goods and services
Engineering and construction
Build Environment, consultants, professional services
provider
Education, training and development
Legal services
To assist the municipality in the categorization process and to ensure that your company is
correctly classified, we require a short summary of your core business, key words that best
describe your business operations and any specializations
Our core business is: _______________________________________________________________
Specializations : ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Supplier comments:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
11. CERTIFICATION OF CORRECTNESS OF INFORMATION SUPPLIED IN THIS DOCUMENT (*)
I/we, the undersigned, who warrants that he/she is duly authorised to do so on behalf of the supplier,
certifies that the information supplied in terms of this document, including the supporting documentation,
is correct and accurate 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 favourable arrangements after such cancellations: and/or,
iii. Impose a penalty on the contractor as provided for in the relevant organisation’s regulations.
Signed on this __________day of ____________________ 20___ at _______________________________
___________________________________ _______________________________
Authorised signature In his/her capacity as
____________________________________
Please print name of authorised signature
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
DECLARATION OF INTEREST (MBD 4)
1. No bid will be accepted from persons in the service of the state.
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 and/or take an oath declaring his/her interest.
3. In order to give effect to the above, the following questionnaire must be completed and Submitted with
the bid.
3.1 Full name
3.2 Identity number
3.3 Company registration
number
3.4 Tax reference number
3.5 Vat registration
number
3.6 Are you presently in the service of the state YES NO
3.6.1 If so, furnish particulars.
3.7 Have you been in the service of the state for the past twelve months? YES NO
3.7.1 If so, furnish particulars.
MSCM Regulations: “in the service of the state” means to be –
(a) a member of –
(i) any municipal council;
(ii) any provincial legislature; or
(iii) the national Assembly or the national Council of provinces;
(b) a member of the board of directors of any municipal entity;
(c) an official of any municipality or municipal entity;
(d) an employee of any national or provincial department, national or provincial public entity or constitutional institution within the
meaning of the Public Finance Management Act, 1999 (Act No.1 of 1999);
(e) a member of the accounting authority of any national or provincial public entity; or
(f) an employee of Parliament or a provincial legislature.
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail:
[email protected] [email protected]/
3.8 Do you, have any relationship (family, friend, other) with persons in the YES NO
service of the state and who may be involved with the evaluation and or
adjudication of this bid?
3.8.1 If so, furnish particulars.
3.9 Are you, aware of any relationship (family, friend, other) between a bidder YES NO
and any persons in the service of the state who may be involved with the
evaluation and or adjudication of this bid?
3.9.1 If so, furnish particulars
3.10 Are any of the company’s directors, managers, principal shareholders or YES NO
stakeholders in service of the state?
3.10.1 If so, furnish particulars
3.11 Are any spouse, child or parent of the company’s directors, managers, YES NO
principal shareholders or stakeholders in service of the state?
3.11.1 If so, furnish particulars
-
Enquiries: Ms S. Marule
Tel : 014 555 1437/1313
Fax: 014 555 6368
E-mail: [email protected]
[email protected]/
4. CERTIFICATION
I, THE UNDERSIGNED (NAME) ____________________________________CERTIFY THAT THE INFORMATION
FURNISHED ON THIS DECLARATION FORM IS CORRECT.
I ACCEPT THAT THE STATE MAY ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE.
Full Name Identity Number Personal Income State
Tax Reference Employee
Number Number /
Persal Number
SIGNATURE DATE
NAME OF
SIGNATORY
POSITION
NAME OF COMPANY
