ANNEXURE A SUPPLIER DECLARATION FORM P a g e

Transcription

1 ANNEXURE A SUPPLIER DECLARATION FORM P a g e

2 Health Professions Council of South Africa This form must be completed and submitted with TENDER: Health Professions Council of South Africa P O Box 205 PRETORIA Madiba (previously known as Vermeulen) Street Arcadia PRETORIA 0007 Please complete the form fully and use a black pen. Illegible or incomplete forms will be rejected. Direct enquiries to Procurement Officer Tel LivhuwaniM@hpcsa.co.za PLEASE KEEP COPIES OF REGISTRATION FORM AND ALL DOCUMENTATION SUBMITTED FOR YOUR RECORDS AS NO COPIES WILL BE MADE BY THE COUNCIL 2 P a g e

3 TYPE OF BUSINESS TYPE OF SERVICE YES NO 1 TENDER REFERENCE NO: HPCSA 5/2016 Professional Legal Services based in all Major centres (eg Johannesburg, Pretoria, Durban, Cape Town, Port Elizabeth, Bloemfontein and East London) Applicants should have experience and/or expertise within the following legal fields: Civil and Criminal Litigation in the Magistrate and High Court Knowledge of and experience in applicable Health Legislation, including the Health Professions Act, 56 of 1974 and its governing regulations Expert legal opinions. Medico legal experience Experience in Labour Law and related processes Experience in conducting Professional Conduct Inquiries Terms and Conditions of this Tender Please note that the HPCSA reserves the right not to accept the lowest tender or any tender in part or in whole. It will award the contract to the tenderer who proves to be fully capable of handling the contract and whose tender is technically acceptable and financially advantageous to the HPCSA. Tenders should be submitted in sealed envelopes must be placed in a tender box at the Main Reception area of the HPCSA Building, 553 Vermuelen Street, Arcadia, by no later than 30 September 2016 at 12:00 The tender number, the subject and return date thereof must also be endorsed on the envelope. Kindly state the centre you belong in Tenders/hard copies can be couriered and placed in a Tender Box No tender received by telegram, facsimile, post and/ or will not be considered. Where a tender is not in the tender box at the time of the tender closing, such a tender will be regarded as a late tender. Late tenders shall not be considered. Amended tenders may be sent in an envelope marked, Amendment to Tender and should be placed in the tender box before the closing date and time. Kindly note that the HPCSA is entitled to amend any tender conditions, validity period, specifications or extend the closing date of tenders. All tenderers who submitted tenders, will be advised in writing of such amendments timeously. All tenders must contain sufficient information with regard to relevant experience, depth of skills, technology advancements within the company and flexibility of the company s processes to adapt to the HPCSA s requirements. Successful applicants will be required to enter into service level agreements with the HPCSA in addition to contractual obligations. The HPCSA reserves the right without furnishing reasons whatsoever, to award or not to award this tender to any tenderer(s) if (the HPCSA) deems fit or not fit notwithstanding the fact that other tenderers may have submitted better or equally acceptable tenderers. A representative of the successful tenderer must be prepared to travel to Pretoria to be interviewed by a Committee appointed by the HPCSA to oversee this process. Failure to comply with any of the conditions as set out above will invalidate the tender. Responding to the request does not automatically qualify the suppliers as registered or preferred service providers. Should you not receive a response within 3 months of the closing date, please regard your proposal as unsuccessful. Successful applicants will be required to negotiate their rates with the HPCSA. Deadline for tender submission: 30 TH September 2016 at 12H00 (South African Standard Time) 3 P a g e

4 Where applicable under mentioned documents must be attached with tenders Please tick box BEE/B-BBEE Status A valid B-BBEE Verification Certificate issued by a Registered Auditors approved by the Independent Regulatory Board of Auditors [IRBA) or South African Accreditation System (SANAS) Company registration document (certified) Proof of ownership/ shareholder certificate (certified) If applicable; a Joint Venture agreement (certified) Valid Tax clearance certificate (original) Proof of banking document Level of empowerment from a shareholding and management perspective, including the repress entivity of blacks & women from the shareholding and management perspective List of at least three references. The company s existing business relationship with the HPCSA (if applicable) Comprehensive company profile Duly signed HPCSA supplier declaration form A copy of your audited financial statements Y N NA Name of Business BUSINESS PARTICULARS Physical address City Province Postal address (if not same as above) 4 P a g e

5 City Province Telephone Fax no Cell no address Web page address Contact person for correspondence address Name Surname Sales Department SALES AND ACCOUNTS DEPARTMENTS Contact name Telephone Fax address Cell no 5 P a g e

6 Accounts Department FINANCIAL DETAILS (BANKING) Banking institution name Branch Town/City Banking account number Account type Account holder s name NB: Documentary proof of banking institution must be supplied confirming banking details, including either an: - original cancelled cheque; or - Original stamped letter from Bank. 6 P a g e

7 HDI INFORMATION Explanation of abbreviations used in the following tables: Capacity HDI status Director D HDI H Partner P Women W Member M Disabled D Priority Other R O Proof of disability provided by a recognized institution in the case of handicapped persons must be supplied. NB: certified copy of shareholder certificates or proof of ownership must be supplied Complete the following for the shareholders who are actively involved in the management and daily business operation of the business. First name Surname Identification number Capacity D P M R O M F (sex) HDI status H W D Disabled (permanent impairment of a physical, intellectual or sensory function resulting in restricted or lack of ability to perform in a manner considered in a manner considered normal for a human being). Are you actively involved in the management and daily business operations of the business? (please provide a written breakdown e.g. company profile). First name Surname 7 P a g e

8 Identification number Capacity D P M R O M F (sex) HDI status H W D First name Surname Identification number Capacity D P M R O M F (sex) HDI status H W D 8 P a g e

9 CONTACTABLE REFERENCES Please supply a list containing the names, telephone numbers and client relationship of a minimum of three contactable references Contact person 1 Contact number 1 Client Relationship 1 Contact person 2 Contact number 2 Client Relationship 2 Contact person 3 Contact number 3 Client Relationship 3 9 P a g e

10 PREVIOUS CONTRACT OR TENDERING EXPERIENCE (Mark with X) Do you have any previous contract work or tendering experience? Yes No If yes, please complete the table below. List the last two contracts awarded to you or previous experience with other businesses related to this of work or supply Employer/ Department Contact person Contact number Estimated contract value in rands Year awarded Proof documents attached Yes NO Did your business exist under a previous name? If yes, what name did it trade under? Previous business registration number 10 P a g e

11 Certification of correctness of information supplied in this document 1. The information supplied is correct. 2. All copies of relevant information are attached. Personal information in block letters Name Surname Telephone Capacity On behalf of the (supplier s Name) Signed and sworn to before me at on this the day of 2016 by the Deponent, who has acknowledged that he / she knows and that understands the contents of this Affidavit, 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, and that the prescribed oath will be binding on his/her conscience. Signature: Applicant on behalf of supplier Signature: Commissioner of Oath Commissioner of Oath Official Stamp 11 P a g e

12 Please complete in block letters Company name/surname Authorization for electronic transfer of funds (EFT) Company Account Holder Address Telephone Fax Mobile Bank Branch Bank Account Branch number Type of Account Cheque Savings Transmission Date Signature For use of bank (in cases where a cancelled cheque or bank letter is not attached) Above information checked and confirmed Signature: Bank Stamp: 12 P a g e

13 SUPPLIER QUESTIONNAIRE In assessing the company s tender the HPCSA tender committee will consider the information provided as outlined in all the sections of this tender document. ANNEXURE B. SERVICES 1. Where are your offices located? And based on your answer? 2. Number of years in business? 3. Are you involved in any community development programmes if yes, please give details 4. Are you prepared to negotiate on price? 5. Do you accept payment via EFT? QUESTIONNAIRE COMPLETED BY: NAME: SIGNATURE: COMPANY STAMP DATE: 13 P a g e