REPUBLIC OF SOUTH AFRICA [DISTRICT MUNICIPALITY NAME]

District Municipality Logo

REGISTRATION OF NONGOVERNMENTAL ORGANISATIONS

VOLUME 2

RESPONDENT QUESTIONAIRES

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TABLE OF CONTENTS

1. 1.1 1.2 1.3 1.4 1.5 1.6

THE RESPONDENT QUESTIONNAIRES ...............................................................................1 Company /Organisation Information.........................................................................................1 Services Capability Matrix ........................................................................................................2 Specific Project Experience......................................................................................................4 Financial Information ................................................................................................................5 Legal Information......................................................................................................................6 Certification...............................................................................................................................7

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A.

Guideline to this Document

This document consists of two volumes:

Volume 1: Provides background and information regarding the registration prequalification process for Non-Governmental Organisations Volume 2: Contains the registration information required and questionaires to be completed by the respondent or

[Note for Document Compilers: Wherever input from the document compiler is required the font typeset is printed in italics and bracketed.]

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1.

THE RESPONDENT QUESTIONNAIRES

The Respondents are required to provide the following information and completed the following questionnaires: o o o o o o Company Information Services Capability Matrix Specific Project Experience Financial Information Legal Information Certification Section 1.1 Section 1.2 Section 1.3 Section 1.4 Section 1.5 Section 1.6

1.1

Company /Organisation Information Please provide the following information regarding the organisation: 1.1.1 Full company / organisation name and mailing address

1.1.2

Registered office address

1.1.3

Provide a copy of current company / organisation brochure (if available)

1.1.4

Provide the following details of company status:

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a. Brief description of business b. Public , privately, trust , other ownership c. Ultimate holding organisation and whether public, privately, trust etc owned

d. Number of years in business e. Show organization structure. Please submit this information in a separately bound document labelled: Supplemental Information.

1.2

Services Capability Matrix Please complete the Service Capability Matrix below by indicating the relevant service offered [and in which District Municipality, only if for more than one DM area] by inserting a cross in the appropriate box. Please note that the Service Capability Matrix lists services that are usually provided by NGOs in the water sector, please specify any additional services that are offered by the organisation. (See description in Appendix A for guidance on services in Volume 1 of this document) [Guidance Note to Document Compiler: Please use the appropriate Services Capability Matrix depending on the area of operation i.e. either Northern Province, Kwa-Zulu Natal or Eastern Cape. OR revise matrix if area of operation does not fall under one of these provinces] 1.2.1 Province.. [Insert Name of Province] Insert DM area(s)

NGO Name:
Programme Implementing Agent Implementing Agent Sewer/Water/Both Operate Train and Transfer (OTT) Accessing of funds

SERVICES

PHAST Training Business Development Plan

Policy Development Training Agent Water Services Provider (WSP) M&E Facilitation Agent

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Support Agent

Services

Institutional and Social Development Technical Agent Other

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1.3

Specific Project Experience Please complete the table below with full details. Please replicate or copy the table if additional project experience needs to be filled out.

Description Name of District Municipality Province Population served Service provided Extent of service provided (describe fully)

Date of contract commencement Date of contract termination Contract value (Rand) and basis Individual for reference Address, Telephone, Fax for reference

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1.4

Financial Information Please provide the following financial information regarding the organisation in the separately bound document labelled: Supplemental Information:

(a)

A certified copy of the last three independently audited annual financial statements. The most recent financial statement must be provided. Note: Where audited annual financial statements are not available, you may provide financial statements certified by registered accountants or general annual reports produced by the organisation.

(b)

The names, addresses and telephone and fax numbers of the banks or financial institutions who will provide financial references for the organisation. Please note that by submitting the response to this questionnaire the organisation accepts that the Committee may approach the banks or financial institutions named. Any information obtained shall be held in confidence by the Committee and will only be used for evaluation purposes.

(c)

The turnover value (in Rand) of contracts undertaken in each of the last three years in the format shown below.

Fiscal Year 1 2 3

Total Turnover 000 Rand

Totals

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1.5

Legal Information Please provide the following legal information regarding the organisation in the separately bound document labelled: Supplemental Information: (a) The organisations registered name.

(b)

Summary details of any violation of wage or other fair labour practices and standards that the organisation has been found guilty of. If none, state so.

(c)

Provide details of any occurrences of default on a contract, or disqualification or being barred from bidding by the organisation. If none, state so.

(d)

Details of any project that the organisation has failed to complete or has been terminated. If none, state so.

(e)

State any lawsuits or legal actions arising from projects undertaken by the organisation during the last ten years. Describe the action, whether the organisation in question was the plaintiff or defendant and the outcome or decision of the case. If none, state so.

(f)

Give details of any conviction or investigations by the organisation for a violation of the criminal law or any other regulations or requirements relating to environmental matters or any other matters relevant to its business. If none, state so.

NOTE:

Provide

details

for

the

last

three

years

unless

stated

otherwise.

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1.6

Certification

CERTIFICATION
I, . . . . . . . . . . . . . . . . . . . . , being duly sworn, state that I am the authorized representative of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (the organisation) being considered as a potential registered Respondent as an NGO. I have read and understand all of the terms, conditions, instructions and questions in this document.

I certify that I have examined all of the answers to each question in the Respondents Questionnaires and further, that, to the best of my knowledge, information and belief, all of the information and answers supplied by my organisation are full, complete and truthful.

I recognize and understand that the sole purpose of this questionnaire is for the Committee to register or pre-qualify Respondents.

I acknowledge that the Committee may, at its discretion, act to confirm the truth and accuracy of all the statements and answers made in this questionnaire and hereby authorize the Committee to do so and to make whatever inquiries the Committee deems to be necessary to confirm the truth and accuracy of all the statements and answers made in this questionnaire.

Name (Printed): Designation: Signed: Date:

NGO_Prequal_vol_2.doc

NGO Registration or prequalification document