School of Public Service & Health Public Administration PADM 520

Suppliers DatabaseRegistration Form

Supplier Name

ZNT 31

FOR OFFICE USE

Registration Number

Date

Date

D D M M Y Y Y Y

D D M M Y Y Y Y

Captured By

Approved By

KWAZULU-NATAL PROVINCIAL TREASURY

DELIVER TO :

SUPPLY CHAIN MANAGEMENT OFFICETREASURY HOUSEGROUND FLOOR

145 CHIEF ALBERT LUTHULI ROADPIETERMARITZBURG

3200

SUPPLY CHAIN MANAGEMENT OFFICEPRIVATE BAG X9082PIETERMARITZBURG

3200

ENQUIRIES

TEL. (033) 897 4483 / 897 4235 / 897 4231TOLL FREE. 0800 201 049

OR POST TO :

Page 1

INTRODUCTION

The ZNT 31 was specifically designed to provide for the registration of suppliers on the KwaZulu-Natal Provincial

Suppliers Database.

In order to ensure that suppliers are considered legitimate, it is imperative that the following guidelines are adhered to.

GUIDELINES

Applicants must complete pages 2 to 13, where applicable. Failure by an applicant to provide ALL the prescribed information and documents required will result in non-registration. If the information required is not applicable to your business; clearly insert the symbols “N/A” in the appropriate space. All mandatory fields marked by two asteris** are to be filled in. If the space provided is left blank and or mandatory fields are not filled in, it will be regarded as information that is still outstanding and you WILL NOT be registered. Only black ink is to be used when filling in the form.

· Applicants are advised that only ORIGINAL ZNT 31 or PHOTOSTAT copies thereof will be processed. Any document

that has been retyped or redrafted will be disregarded and returned to the applicant.

· It is imperative that only supporting documents with an ORIGINAL signature be submitted.

· All signatures to the document must be commissioned by an authorised Commissioner of Oaths. Failure to do so will

result in the applicant not qualifying for registration.

· A supplier registered on the Suppliers Database MUST notify the Supply Chain Management Office of any

changes to information provided in the initial ZNT 31, as captured onto the Suppliers Database. Failure to do so

may result in such a supplier being removed from the Suppliers Database and/or the cancellation of contracts

awarded to the supplier, on the basis of misrepresentation.

· Suppliers providing information incorrectly or fraudulently in their ZNT 31 will be disqualified from bidding and

removed from the Suppliers Database, in addition to any other action the Province may institute against such a supplier.

Furthermore, in the event of the Province being prejudiced financially, it reserves the right to take legal action against

the supplier.

· For definitions of terminology used in this document, please refer to the definitions set out in Treasury Regulation 16A

and the KwaZulu-Natal Supply Chain Management Policy Framework, located on the KwaZulu-Natal Treasury's

website, www.kzntreasury.gov.za

· Any alterations made by the supplier to its own information inserted on this document, must be initialed by the

supplier. The use of correcting fluid is prohibited and the use thereof will lead to non-registration of the applicant

business/supplier.

SECTION A: INSTRUCTIONS

· Electronic forms are available on the website: www.kzntreasury.gov.za , Select ” Supplier Database” .

· Reminder letters will be issued by the KwaZulu-Natal Provincial Treasury to suppliers to update their information. It

remains the responsibility of the supplier to ensure that their information is updated in the Suppliers Database, therefore

if a reminder letter is not received, the supplier must follow up with Provincial Treasury.

Page 2

Your current database registration number (ZNT number)

PLEASE USE BLOCK LETTERS.

The following information must be filled in by the applicant. Failure to submit ALL the required information maylead to non-registration of the applicant's business

Name of business as registered with the Registrarof Companies

Registration number of Company/CC/Trust/Fund number

Postal codeBusiness Postal address

Business Physical address Postal code

Telephone number

E-mail address

Cellular phone number

Website address

Preferred language English AfrikaansIsiZulu

Contact person (Full Name & Surname)

Physical location of HeadOffice (if applicable)

1. Business particulars **

T E L E P H O N E C O D E C O D EFacsimile number F A C S I M I L E

SECTION B: COMPANY INFORMATION

Holding company

2. Financial information **

Bank branch number (at least six numbers)

Name of bank account holder

Type of bank account Current Savings Transmission1 2 3

Bank account number

Trading as

UIF number

Compensation Commissioner registration number

Income tax reference number

PAYE number 7

Financial year-end D D M M

VAT registration number 4

N.B: A certified copy of a tax clearance certificate must be supplied

Tax clearence certificate issue date

Tax clearence certificate expiry date

D D M M Y Y Y Y

D D M M Y Y Y Y

N.B: A certified copy of latest bank statement or original cancelled cheque or original letter from your bank must beattached.

R

R

R

R

R

Total fixed assets at book value (e.g. land, buildings, plants, equipment)

3. Indicate the value of the below stated based on the latest financial statement **

Vehicles at book value

Number of vehicles

Average stock on hand

Cost of goods produced annually

Quantity produced annually

Units of measure (e.g. tons, kilolitres)

Total current assets (e.g. stock, debtors, cash)

Total current liabilities (e.g. creditors, bank overdraft)

4. Municipalities **

Please clearly indicate, with an 'X', the District Municipality/s where your business operates.

5. Previous business information (if applicable)

Did your business exist under a different name previously? ORYes No

If "yes" what was the previous business name?

What was the previous database registration number (ZNT number)?

6. Previous experiences (If applicable)

SurnameInitials

Was the project completed successfully? (Mark applicable block with an "X") ORYes No

Employer/Department

Contact person

Telephone number T E L E P H O N E C O D E C O D EFacsimile number F A C S I M I L E

Y Y Y YWhat year was the project initiated?

What was the contract value? R

CONTRACT 1

List the last three (3) contracts awarded to you ( the supplier) or other previous experience related to yourcore business

Page 3

eThekwini Municipality (DC 20)

Ugu Municipality (DC 21)

Umgungundlovu Municipality (DC 22)

Uthukela Municipality (DC 23)

Umzinyathi Municipality (DC 24)

Amajuba Municipality (DC 25)

Zululand Municipality (DC 26)

Umkhanyakude Municipality (DC 27)

uThungulu Municipality (DC 28)

Ilembe Municipality (DC 29)

Sisonke Municipality (DC 47)

Page 4

SurnameInitials


Employer/Department

Contact person




CONTRACT 2

SurnameInitials


Employer/Department

Contact person




CONTRACT 3

SECTION C: CLASSIFICATION OF BUSINESS

A. Public Company LTD

B. Private Company (PTY) LTD

C. Close Corporation CC

D. Incorporated

G. Trust

E. Sole Proprietor

H. Co-Operative

F. Partnership

I. Welfare organisation

Certified copy of certificate of incorporation (CM 1)

Certified copy of certificate of incorporation (CM 1)

Certified copy of CK 1 document and CK 2 if applicable

Certified copy of certificate of incorporation (CM 1 and CM 29)

Certified copy of Identity Document

Certified copy of partnership agreement

Certified copy of trust document

Certified copy of proof of registration with the directorate Co-Operatives

Certified copy of constitution

1. Type of business **

Please mark with an "X" the block applicable to your business or firm AND attach the relevant certified copy

R

Annual turnover R

Number of employees

Total Gross Asset value (fixed property excluded) R

Page 5

2. Products & Services **

In order to assist with the classification of suppliers, please indicate the industrial sector related to the goods /services that you supply (Only a maximum of FOUR industrial sectors may be selected). If the supplier selectsmore than FOUR (4) Industrial Sectors, only the FIRST FOUR will be considered).

Please mark with an "X" the appropriate block to clearly indicate the industrial sector related to the goodsand services that you supply

Finance and Business service

Banking

Insurance

Investments Credit institutions Engineering

Exchanges

Other (Please Specify)

Legal services

Securities broker

Business & management consultants

Chartered accountants

Architects & quantity surveyors

Community, social & personal services

Collectibles & awards

Fitness equipment Cleaning & Janitorial equipment

Field & court sports equipment Winter sports equipment

Gymnatics & boxing equipment

Sports equipment & accessories

Water sports equipment

Janitorial equipment

Camping, outdoor equipment &accessories

Fishing & hunting equipment

Target, table games & equipment

Cleaning & Janitorial equipment

Industrial laundry & dry cleaning equipment

Recreation, playground, swimming, spa equipment & supplies

Water, wastewater treatment supply & disposal


Mining & quarrying

Fuels Lubricants, oils, greases, & anti corrosives

Elements & gases Well drilling & operating equipment

Oil, gas operating & production equipmentOil, gas drilling & exploration equipmentGaseous fuels & additives

Fuel for nuclear reactors

Mining, quarrying machinery & equipment

Oil, gas drilling & operating equipment


Hydraulic machinery & equipment

Transportation components & systems

Marine transport

Structural building products

Transportation services equipment

Aerospace systems, components & equipment

Software

Components for information technology, broadcasting or telecommunications

Non motorized cycles Spacecraft

Railway, tramway machinery machinery & equipment

Computer equipment & accessories

Aircraft

Automotive speciality tools

Data voice, multimedia network equipment or platforms & accessories

Communications devices & accessories

Transport, storage and communication


Page 6

Catering and accommodation and other trade

Edible oils & fats

Meat & poultry products

Dairy products & eggs Restaurant

Bread & bakery products

Sea food

Fruits, vegetables, nuts & seeds

Prepared & preserved foods

Bed & breakfast

Hotels

Lodges

Gambling or wagering equipment

Camps

Vending machines

Liquor outlets

Institutional food services equipment

Media

Museums Zoological gardens Photographic & recording media

Art galleries

Amusement & recreational services

Printing & publishing equipment

Botanical gardens

Photographic filmmaking supplies

Film Music

Photographic, filming or video equipment

Audio, visual presentation & composing equipment

Chocolate, sugars, sweeteners, confectionary products


Agricultural, forestry and fishing

Live animals

Domestic pet products

Floriculture & silviculture products Fertilizers, plant nutrients & hebiciders

Gymnatics & boxing equipment

Animal feed

Pest control products

Fishing & aquaculture equipment

Seeds, bulbs, seedlings & cuttings

Saddlery & harness goods

Agricultural, forestry, landscape material & equipment

Animal containment & habitats


Electricity, gas and water

Power sources

Atomic, nuclear energy machinery & equipment

Heating, ventilation & air circulation

Electrical wire, cable & harness Power generation

Industrial filtering & purification

Batteries, generators & kinetic power transmission

Fluid & gas distribution


Construction

Interior finishing materials

Doors, windows & glass

Structural building products

Insulation

Structural materials & basic shapesPlumbing fixtures

Construction & maintenance support material

Roads & landscape

Permanent structures

Heavy contruction machinery & equipment

Pneumatic machinery & equipment

Hand tools Hydraulic machinery & equipment Automotive speciality tools


Cerial & pulse products

Prefabricated structures

Industrial pumps & compressors

Page 7

Non-Durable goodsDurable goods

Wholesale trade, commercial agents and allied services


Page 8

Retail, motor trade and repair service

Fleet management

Furniture, furnishing & equipment stores

Repair service

Vehicle bodies & trailersMotor vehicles

Petrol stations General merchendise stores

Apparel & accessory stores

Manufacturing

Packing supplies

Packaging materials

Paper materials

Paper products

Machine made partsMachined raw stock

Paints, primers & finishes

Adhesives & sealants

Castings

Industrial refrigeration

Fabricated structural assemblies Housings, cabinets & casings

Dyeing & tanning extracts

Moldings Fabricated bar stock assemblies

Gaskets & seals Magnets & magneting materials

Light weapons & ammunition

Solvents

Laboratory supplies & fixtures

Compounds & mixtures Medical sterilization products

Clinical nutrition

Respiratory, anesthesia & resuscitation products

Metal waste scrap

Lamps & light bulbs

Industrial food & beverage equipmentSurgical products

Dental equipment & supplies

Raw materials processing machinery

Weaving & knitting

Workshop machinery, equipment & supplies

Electronic hardware, component parts & accessories

Fabricated pipe assemblies

Orthopedic, prosthetic & sports medicine products

Textile, fabric machinery & accessories

Wound care products

Postmortem, mortuary equipment & supplies

Grinding, polishing & smoothing materials Bearings, bushings, wheels & gears

Saw milling, lumber processing machinery & equipment

Physical, occupational therapy & rehabilitation products

Emergency & field medical services products



Pag

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Page 10

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Page 12

Identify by name the Historically Disadvantaged Individual (HDI) status and the length of services of theindividuals in the business. Include owners and non owners responsible for the day-to-day Managementand Business decisions.

SurnameInitials

White Black Indian ColouredRace (Mark applicable block with an "X")


Y YNumber of years in service?

Cheque signing

Signing & co-signing for loans

Business financing (overdraft, lease agreements)

Sureties

3. Business management **

Number of years in service?

SurnameInitials

Race (Mark applicable block with an "X")


Y Y


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Y Y

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Page 10

Signature: Date signed D D M M Y Y Y Y

Signed at

SurnameInitials

Signed before The Commissioner of Oaths: (Supplier representative)

Supplier name

Signed by the deponent who has acknowledged that he/she knows and understands the contents of this document and he/she has acknowledged that he/she has no objection to affirming that he/she regards the affirmation to be binding on his/herconscience.

Commisioner of Oaths signature:

Signed and affirmed before me at: (Commissioner of Oaths)

Date signed D D M M Y Y Y Y

SurnameInitials

Business Physical address Postal code

Capacity Area

OFFICIAL STAMP

Page 11

A. The supplier will be required to furnish documentary proof of the information relating to preferences, if requested to do so.

4. Verification of Information **

I/We, the undersigned, who warrants that he/she is duly authorised to do so on behalf of the supplier, certifiesthat the information supplied in terms of this document (ZNT 31) including the annexure/s with additionalinfromation, is correct and accurate and acknowledges that:

B. If the information supplied is found to be incorrect then the Province may, in addition to any remedies it may have:

i Disqualify the supplier/contractor for a particular bid/contract/project it may be considered for, or whichhad been awarded to the supplier/contractor;

ii. Recover from the supplier/contractor all costs, losses or damages incurred or sustained by the Province as aresult of breach of the contract;

iii. Cancel the contract and claim any damages which the Province may suffer by having to make less favourablearrangements after such cancellation: and/or;

iv. De-register the supplier registered on the Supplier Database

Page 12

The following fields have been completed:

Business Particulars

Municipalities

Financial Information

Type of Business

Products & Services

Ownership Information

Business Management

Verification of Information

FOR OFFICIAL USE

Surname

Initials

Date D D M M Y Y Y Y

I acknowledge that this form has been checked by me, and all the required Information/Documents have beenfurnished.

Signed

Certified copy of the Company Registration Certificate

SECTION E: CHECKLIST

The following Documents have been attached:

Supplier For official use

Original Tax Certificate

Proof of Banking Details

Please use this checklist as confirmation that ALL the required Information/Documents have been submitted.Please indicate with an "X".