APPLICATION FORM 2015 APPLICATION TO REGISTER AS A VENDOR INTO NATIONAL LOTTERIES BOARD SUPPLIER DATABASE FOR SUPPLY OF GOODS AND SERVICES 1
SECTION A 1. SUPPLIER DATABASE SUBMISSION In order to comply with the requirements of the Public Finance Management Act of 1999 (PFMA) and to ensure compliance with the Preferential Procurement Policy Framework Act of 2000, (PPPFA) and its regulations, the NLB invites prospective service providers to be added to their Supplier Database. It is envisaged, that this database will contribute to efficient administration and compliance with the PFMA. 1.1 The purpose of this database is to give all prospective suppliers an equal opportunity to submit quotations to NLB. Procurement of all goods and services for NLB is centralised and managed by Supply Chain Management unit, under Finance Division based at our Head Office in Hatfield. 1.2 National Lotteries Board Provincial Offices: Eastern Cape Free State Northern Cape North West Mpumalanga Western Cape Waverley Office Park 3-33 Phillip Frame Road Chislehurst, East London No. 21/322, Corner Stateway and Ryk Roads, Welkom Suite D, 9-11 Roper Street, Kimberly Henque Building, 2313 Aerodome Cresent (Parallel to Nelson Mandela Drive) Mafikeng 25 Roodt Street Sonheuwel Dorp, Nelspruit 4 th Floor, Manhattan Place, 130 Bree Street, Cape Town 1.3 N.B: The Supplier Database registration schedule for 2015 Submission Submission Closing Date 20 March 2015 All submissions should reach the NLB Provincial Offices before closure of business on the stipulated closing date. NLB office hours are between 8:00 am and 16:30 2
2. REQUIRED DOCUMENTATION AND EVALUATION CRITERIA: No Description Special Special Instruction 1 Instructions for completion To be completed in full 2 Products and services Select applicable services that can be supplied or rendered 3 Vendor Information Form To be completed in full 4 Certified copy of Company registration documents (CIPRO) certificate. Attached to registration document 5 Declaration of interest To be complete and signed 6 Tax clearance requirements Valid original tax clearance certificate must be Submitted. Where partnerships, Consortia / Joint Ventures / Sub-contractors are involved each party must submit a separate Tax Clearance Certificate. 7 Preference point claim form To be completed in full and signed (SBD6.1) 8 General conditions of contract Each page must be initialled 9 Company profile and shareholding certificate Attached to registration document 10 Certified and Valid copy of BEE Certificate 11 Individual/partners/shareholders/m ember certified ID copies 12 Letter from the bank with valid stamp to confirm banking details 13 Any other certificate pertaining to your relevant industry. Attached to registration document Attached to registration document Attached to registration document Attached to registration document Failure to comply with all of the above criteria and completion of the forms as required, as well as submission of supporting documentation will result in the application being disqualified. Kindly note, (3) contactable references and the value of past three services rendered must be submitted. Service Providers will only have an opportunity to apply for or select a maximum of 3 commodity categories. Company profiles, leaflets and brochures are also welcomed. 3
3. INSTRUCTIONS FOR COMPLETION (Please read carefully) Information and Certificates must be updated at least once a year. All the forms should be completed either electronically (Signature should be in the original) or by hand legibly and with a black pen). Please clearly mark envelopes with the title 2015 Supplier Database Registration, addressed specified above. The service/s for which the organisation would like to be registered must be marked by putting a cross (x) in the applicable column in the list of services hereunder. The province/s that the supplier is applying for must be clearly marked by putting(x) next to the province name. 3.1 Queries All queries must be addressed in writing and to SCM Office (only) at database@nlb.org.za with the subject heading 3.2 Applications without the relevant aforementioned information shall be disqualified. 4 TERMS AND CONDITIONS: 2.1 Any service provider whose name appears on the Tender Defaulters and the National Treasury s Database as a person/entity prohibited from doing business with the public sector will not be considered. 2.2 Only signed original application forms will be accepted. No emailed, faxed, incomplete or incorrect submissions will be accepted. 2.3 The NLB reserves the right to accept or reject any application. 2.4 The NLB reserves the right to conduct site visits where deemed necessary. 2.5 Supplier shall be responsible to ensure that information is updated as and when such change occurs. Information must be submitted to the NLB s Supply Chain Management Unit. 2.6 NLB will monitor supplier s performance on projects awarded. The evaluation will assist NLB on any future work that may be awarded. SECTION B PROVINCE New supplier Supplier Update Please tick the relevant box (X) 4
1. COMPANY/SUPPLIER DETAILS Kindly complete this document accurately as the information contained herein is required for the following purposes: To support NLB in the implementation of a system of preferences as required by the Preferential Procurement Policy Framework Act (No 5 of 2000). Failure to complete the form in full may result in the supplier not being considered for the awarding of any orders or contracts by the NLB. Legal name of company: Trading name of company: Tax Clearance Certificate Number: Tax Clearance Expiry Date: Vat Number: Income Tax Reference Number: Company Registration Number: 2. CONTACT DETAILS 2.1 Main Contact Person: Title: Initials: Surname: Position Held: Business Telephone Number: Mobile Number: Facsimile: Email Address: Company Website Address: 2.2 2 nd Contact Person: Title: Initials: 5
Surname: Position Held: Business Telephone Number: Mobile Number: Facsimile: Email Address: 3. ADDRESS DETAIL Postal address of company Physical address of company 4. TYPE OF COMPANY (INDICATE WITH X AND PROVIDE DOCUMENTARY PROOF) Supplier Grouping Detail: Type of Firm 1. Public Company (Ltd) 2. Private Company (Pty) Ltd 3. Close Corporation (cc) 4. Section 21 Company 5. Joint Venture 6. Consortium 7. Sole Proprietor 8. Foreign Company 9. Partnership 10. Trust 11. Government / Parastatal 12. Other (specify) Please tick the relevant box 6
5. NAMES OF ALL OWNERS, DIRECTORS/MEMBERS AND THEIR RESPECTIVE DESIGNATIONS Names of Owners/Directors/Members Designation 6. LIST OF COMMODITIES REQUIRED (PLEASE SELECT A MAXIMUM OF FIVE (3) a) Procurement and Administration: Cleaning services & products (PA1) Printing (PA2) Stationery (PA5) Catering services (PA6) Cartridges/Toners (PA7) Computer Equipment & Accessories (PA8) Cutlery & Crockery (PA9) General Building Maintenance (PA10) Groceries / Food Parcels (PA11) Office Maintenance (PA12) Office Furniture (PA13) Security Services (PA14) Off-site Corporate Storage Facilities (PA17) Space Planning and Layout (PA18) Signage (PA19) Electrical Supplies (PA20) Plumbing Services (PA21) Hygiene & Pest Control (PA22) Strategic Planning (PA23) b) Human Resources: Recruitment and Placement (HR1) c) Marketing and Public Relations: Advertising Services (MPR1) Event Management (MPR5) Media Services (MPR6) Media Monitoring Services (MPR7) Design and Layout (MPR8) Video and Related Services (MPR9) Audio Visual System (MPR10) Sound & Recording System (MPR11) Web Design, Development & Hosting (MPR13) Editorial Services (MPR14) Motivational speaker (MPR15) Other related services (MPR16) 7
Other related services (PA24) d) Information Technology and Communications: Telephone Services (IT1) Telephone/PABX Maintenance (IT2) IT Software & Hardware Suppliers (IT3) IT Maintenance (IT4) Data Warehousing (IT5) Website Development and Maintenance (IT6) Other related services (IT7) Accounting Systems Software ICT Services 7. LIST OF COMMODITIES TO BE OFFERED Please select the above commodities and indicate below the type of goods/services to be offered. Select maximum of three (3) commodities. Commodities Code from the category listed above 8. CORE BUSINESS & SPECIFIC EXPERTISE VESTED IN COMPANY 8
9. ANNUAL BUSINESS TURNOVER (AMOUNT IN RANDS) 10. MONETARY VALUE OF CONTRACTS & MAXIMUM QUANTITIES THAT CAN BE SUPPLIED AND FREQUENCY OF DELIVERY OR ANY OTHER INFORMATION Monetary value to be supplied Maximum quantities to be supplied 9
11. LIST ALL SHAREHOLDERS BY NAME, POSITION, IDENTITY NUMBER, CITIZENSHIP AND OWNERSHIP (PLEASE COMPLETE TABLE BELOW) Name ID Number Date Occupied in Enterprise Position Occupied in Enterprise Date of citizenship obtained in RSA Composition of Company Race (A/W/I/ C) Gender (F/M) Disabled Percentage (%) of Business/ Enterprise Owned 10
12. Banking Details Bank: Branch Code: Branch Location: Account Holder: Account Number: Account Type: NB: Please attach an original cancelled cheque/or bank stamp/or letter of confirmation from the bank verifying details. 13. DECLARATION OF APPLICANTS PAST SUPPLY CHAIN MANAGEMENT PRACTICES a. b. c. d. Is the company or any of its directors listed on the National Treasury s database as companies or persons prohibited from doing business with the public sector? If so furnish particulars: Is the company 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)? If so furnish particulars: Was the company or any of its directors convicted by a court of law (including a court outside of the Republic of South Africa) for fraud or corruption during the past five years? If so furnish particulars: Was any contract between the bidder and any organ of state terminated during the past five years on account of failure to perform on or comply with the contract? If so furnish particulars: YES YES YES YES NO NO NO NO 11
14. CERTIFICATION I/We the undersigned, who warrant/s that he/she/we is/are duly authorized to do so on behalf of the company, certify that the percentage ownership/shareholders claimed are actively involved in the day to day management of the enterprise and I/we acknowledge that: a. The information furnished on this form is true and correct b. In the event of a contract being awarded as a result of the above mentioned information, the contractor may be required to furnish documentary proof to the satisfaction of the National Lotteries Board that the information is correct. c. I/we accept that, in addition to cancellation of a contract, action may be taken against me/us should the information furnished prove to be false. SIGNATURE OF OWNER OR REPRESENTATIVE: DATE: NAME IN BLOCK LETTERS: SIGNATURE OF OWNER OR REPRESENTATIVE: DATE: NAME IN BLOCK LETTERS: SIGNATURE OF OWNER OR REPRESENTATIVE: DATE: WITNESSES: 1... 2. 12