1. Bcrm Database Reg Form

7/31/2019 1. Bcrm Database Reg Form

1/8

VAT / BTW REG.No: 4 900 193 782 www.bluecraneroute.gov.za

1.1 Handelsnaam van onderneming - Trade name of enterprise - Igama lokushishina loshishino

1.2 Posadres - Postal address - Idilesi yeposi

1.3 Plaasnaam / Besigheid straat adres - Name of Farm / Business street address - Igama lefama / idilesi yesitrato soshishino

1.4 Aard van bedrywigheid wat beoefen word Nature of activities conducted Uhlobo lwemisebenzi eyenziwayo necandelo

1.5 Tipe onderneming (Merk met X) - Type of enterprise (Mark with X) - Uhlobo loshishino (Phawula ngo-X)01 Eenmansaak

Sole Proprietor Ushishino lomntu omnye

02 VennootskapPartnershipUthelelwano

03 Openbare Sektor Public Sector Icandelo lomntu wonke

04 Maatskappy / Beslote KorporasieCompany / Close CorporationInkampani / imbumba evalekileyo

05 Ander: Klub, Trust, ens.Other: Club, Trust, etc.Ezinye: umbutho, itrasti, njl-njl.

1.6 CIDB nommer / CIDB number / inombolo ye-CIDB(Construction Industry Development Board)

1.7 BTW nommer / VAT number / inombolo ye- VAT ..

1.8 Inkomstebelastingverwysingsnommer van persoon / onderneming in 1.1 genoemIncome Tax reference number of person / enterprise mentioned in 1.1

Inombolo yesalathiso serhafu yengeniso yomntu / yoshishino olubalulwa ku- 1.1 ....

1.9 Indien u nie vir enige van bogenoemde geregistreer is nie, meld redes: / If you are not registered for any of the above, furnish reasons: /Xa ungazibhaleli nayiphi na into engaphezulu, nika izizathu:

2.1 Besonderhede van verantwoordelike persoon of eienaar / Particulars of responsible person or owner / Iiinkcukacha zomntu

othatha uxanduva okanye zomnini

2.1.1 Van / Surname / Ifani

2.1.2 Voornaam / First name / Amagama2.1.3 Hoedanigheid / Designation / Ubume emsebenzini

2.2 Besonderhede van skakelbeampte / Particulars of liason officer / Iinkcukacha zomntu womanyano (Umntu onika iimbuyiselo)2.2.1 Voorletters en van / Initials and surname / Oonobumba

bokuqala bamagama nefani

2.2.2 Hoedanigheid / Designation / Ubume bomsebenzi

2.2.3 Selfoon / Cell phone / Iselfoni 2.2.4 Telefoonnommer / Telephone number / inombolo yefoni 2.2.5 Faksnommer / Fax number / Inombolo yeFeksi

2.2.6 e-pos adres / e-mail address / I-imeyile

Ek verklaar dat die inligting wat hierin verstrek is, waar en juis is. / I declare that the information herein furnished, is true and correct. / Ndixelaukuba ulwazi olunikiweyo apha luyinyaniso kwaye lulungile.

.. Handtekening van persoon verantwoordelik vir hierdie verklaring / Signature of person responsible for this declaration / Usayino lomntu othathela uxanduva le ngxelo.

.... .. . Naam / Name / Igama Hoedanigheid / Designation / Ubume emsebenzini Datum / Date / Umhla

Blue Crane

Route

MUNISIPALITEIT 042 243 1333MUNICIPALITYUMASIPALA

BCRM - C1 VerklaringDeclaration

inkcazo

SOMERSET EAST

Nojolistraat 67 Nojoli Street21 5850

Tel. 042 243 1333 Faks/Fax. 042 243 2250

KantoreOfficesIiofisi

MUNISIPALITEIT / MUNICIPAL / UMASIPALA DEPOTS:

PEARSTON Voortrekker Street, Tel. 042 246 1110COOKHOUSE Main Road, Tel. 042 247 1166

KREDITEURE: Registrasie op databasis ingevolge:1. Wet op die Raamwerk vir Voorkeurverkrygingsbeleid, 2000 (Wet No. 5 van 2000) (Goewermentskennisgewing No.97 van 03 Februarie 2000

Staatskoerant No. 20854)2. Voorkeurverkrygingsregulasies (No. R.725 van 10 Augustus 2001) uitgevaardig ingevolge bogemelde Wet (Staatskoerant No. 22549)3. Wet Op Plaaslike Regering: Munisipale Finansile Bestuur No. 56 Van 2003

CREDITORS: Registration on data base in terms of:

1. Preferential Procurement Policy Framework Act No. 5 Of 2000 (Government Notice No.97 van 03 February 2 000 Government Gazette No. 20854)2. Preferential Procurement Regulations (No. R.725 of 10 August 2001) promulgated in terms of abovementioned Act (Government Gazette No. 22549)3. Local Government: Municipal Finance Management Act No. 56 Of 2003

Abantu eninamatyala kubo

Ubhaliso kwindawo ekugcinwa kuyoiindawo ezaziwa ngento ngokuphathelele. .

1. Ubume benkqubo ekhethekileyo yokufumana Umthetho ongunombolo 5 ka-2000 (Isaziso sikaRhulumente esingunombolo 97 we-3 kaFebruwari 2000-Iphepha-ndaba lombuso likaRhulumente unombolo 20854)

2. Imithetho yenkqubo ekhethekiuleyo yokufumana (Nombolo R725 ka-Agasti 2001) umthetho owaziswe ngokubhekiselele ngumthetho ongasentla (Iphepha-ndaba lombuso likaRhulumente elingunombolo 22549)

3. Umasipala wengingqi: Umthetho wokulawula ezemali kamasipala ongunombolo 56 ka -2003


2/8

VRAELYS VIR VOORKEURVERKRYGINGSBELEIDQUESTIONNAIRE FOR PREFERENTIAL PROCUREMENT POLICY

IPHEPHA LEMIBUZO YENKQUBO EKHETHEKILEYO YOKUFUMANA

.. Besigheid of persoon se naam:- / Business or person's name:- / Igama leshishini okanye lomntu

**1. Persentasie aandeelhouding van persone (HBI) in die besigheid wat histories benadeel is as gevolg vanonregverdige diskriminasie gebaseerd op ras .

%Percentage of shareholding of persons (HDI) in the business historically disadvantaged because of unfair discrimination based on race .

Ipersenti yesabelo sabantu kwishishini elalisakuthinteleka ekuxhamleni amalungelo athile ngenxayobandlululo ngokobuhlanga .

2. Persentasie aandeelhouding van persone (HBI) in die besigheid wat histories benadeel is as gevolg vanonregverdige diskriminasie gebaseerd op geslag .

%Percentage of shareholding of persons (HDI) in the business historically disadvantaged because of unfair discrimination based on gender .

Ipersenti yesabelo sabantu kwishishini elalisakuthinteleka ekuxhamleni amalungelo athile ngenxayobandlululo ngokwesini .

3. Persentasie aandeelhouding van persone (HBI) in die besigheid wat histories benadeel is as gevolg vanonregverdige diskriminasie gebaseerd op gestremdheid .

%Percentage of shareholding of persons (HDI) in the business historically disadvantaged because of unfair discrimination based on disability .

Ipersenti yesabelo sabantu kwishishini elalisakuthinteleka ekuxhamleni amalungelo athile ngenxayobandlululo ngokobulwelwe .

4. Persentasie aandeelhouding van persone geklassifiseer as jeug . (18 35 Jaar oud).%Percentage of shareholding of persons in the business classified as youth . (18 35 Years old)

Ipersenti labantu abanezabelo kwinkonzo zoshishino ababizwa ngokuba lulutsha (18 35 Yeminyaka)

5. Is u besigheid gele binne die jurisdiksie van die munisipaliteit ? In / Uit In/NgaphakathiIs your business established within the area of jurisdiction of the Municipality? In / OutIngaba ishishini lakho limi kwingingqi elawulwa nguMasipala? Ngaphakathi / Ngaphandle Uit/Out/Ngaphandle

6. Maak u gebruik van plaaslike arbeid (werkskepping)? Ja / Nee Ja/Yes/EweDo you make use of local labour (job creation)? Yes / NoUyawasebenzisa amathuba avelayo odalo lomsebenzi (ukudala umsebenzi)? Ewe / hayi Nee/No/Hayi

Hiermee sertifiseer ek/ons die ondergetekende en die getuienisse dat bogenoemde inligting korrek is.I/We hereby certify that the abovementioned information is correct signed by myself/ourselves and the witnesses.-Mna/Thina siqinisekisa ukuba ezi nkcukacha zingasentla zilungile kwaye zisayinwe ndim/sithi kunye namangqina

Getuie/As Witness/--Njengengqina ................................................................Handtekening / Signature / Osayinileyo 1. .... .................................

2. ...............................................................LW! / NB! / -QAPHELA!

Om Voorkeurpunte te eis MOET gesertifiseerde afskrifte van Identiteitsdokumente hierby aangeheg word.To claim Preference points, certified copies of Identity Documents MUST be attached.Ukuba ufuna ukwenza ibango lamanqaku akhethekileyo, KUFUNEKA ukuba isicelo sakho sihambe kunye nekopi yencwadi yesazisisakho (ID) eqinisekisiweyo.

**"Histories Benadeelde Individu (HBI)" Suid -Afrikaanse burger (1) wat weens die apartheidsbeleid wat in plek was, voor die instelling van die Grondwet van die Republiek van Suid-Afrika, 1983 (Wet Nr 110 van 1983) of die Grondwet van die Republiek

van Suid-Afrika, 1993 (Wet Nr 200 van 1993) ("die tussentydse Grondwet") geen stemreg in nasionale verkiesings gehad het nie; en/of (2) wat vrou is; en/of (3) wat gestremd is;

Met dien verstande dat persoon wat Suid -Afrikaanse burgerskap bekom het by of na die inwerkingtredin g van die tussentydse Grondwet, geag word nie HBI te wees nie;

** "Historically Disadvantaged Individual (HDI)" means a South African citizen - (1) who, due to the apartheid policy that had been in place, had no franchise in national elections prior to the introduction of the Constitution of the Republic of South Africa, 1983 (Act No

110 of 1983) or the Constitution of the Republic of South Africa, 1993 (Act No 200 of 1993) ("the Interim Constitution") ; and / or (2) who is a female ; and / or (3) who has a disability ;

Provided that a person who obtained South African citizenship on or after the coming to effect of the Interim Constitution, is deemed not to be an HDI.**Xa kuthethwa ngomntu owanyhashelwa amalungelo akhe k uthethwa ngommi waseMzantsi Afrika

(1) owathi ngenxa yenkqubo yocalucalulo ekwakusakulawulwa ngayo akabi nalo ilungelo lokuvota phambi kokwaziswa komgaqo siseko weRiphabliki yoMzantsi Afrika,1983 (Umthethoongunombolo 110 ka-1983) okanye Umgaqo siseko weRiphabliki yoMzantsi Afrika,1993 (Umthetho ongunombolo 200 ka- 1993) (Umgaqo siseko wethutyana ); kunye / okanye

(2) ongumfazi;kunye/okanye(3) okhubazekileyo;

Xa ubani efumene ilungelo lokuba ngummi waseMzantsi Afrika ngexesha okanye emva kokusetyenziswa komgaqo siseko wethutyana lowo akathatyathwa njengomntu onyhashelweamalungelo ache.

LW! IN GEVOLGE WETGEWING MOET 'N BELASTINGUITKLARING HIERDIE REGISTRASIE VERGESEL.NB! IN TERMS OF LEGISLATION A TAX CLEARANCE MUST ACCOMPANY THIS REGISTRATION.

-QAPHELA! NGOKUPHATHELELE KWEZOMTHETHO OLU BHALISO KUFUNEKA LUKHATSHWESISIQINISEKISO SOKUBA AKUNATYALA LARHAFU.


3/8

TO QUALIFY FOR SMME STATUS PART 2. MUST BE COMPLETED:


4/8

MARK WITH X THE CATEGORY OF COMMODITIES / SERVICES YOU CAN SUPPLY CODE MAIN COMMODITY X CODE MAIN COMMODITY X10000 CONSTRUCTION EQUIPMENT AND SUPPLIES 40300 Picture framing10010 Air conditioning and temperature control equipment 40310 Printing

10020 Building equipment and accessories (cement mixers, scaffolding,trowels, levels, etc) 40320 Procurement services

10030 Building materials (bricks, cement, sand, painting, plastic, stone,steel, tiles, etc) 40330 Real estate services

10040 Ceiling boards, skirtings, etc 40340 Research services10050 Construction machinery 40350 Security and safety services10060 Doors and windows 40360 Site cleaning10070 Electrical systems, lighting, components accessories and supplies 40370 Social Facilitating10080 Flooring materials (carpets, tiles, etc) 40380 Storage10090 Plumbing ware and materials 40390 Translation and interpreting services10100 Roofing materials 40400 Transport services, general10110 Sanitation ware and equipment 40410 Travel services

40420 Vehicle hire20000 CONSTRUCTION SERVICES 40430 Vending services20010 Burglar proofing and systems20030 Concrete manufacture and works 50000 OFFICE AND FACILITIES EQUIPMENT AND SUPPLIES20040 Construction-related transport 50010 Computer equipment, networks and software20050 Demolition services 50020 Consumables20060 Earthworks, drilling and landscaping 50030 Corporate gifts20070 Electrical installation 50040 Domestic, industrial and cleaning equipment and supplies20080 Fencing 50050 Electronic equipment, including audio-visual equipment20090 General building work 50060 Fire protection equipment20100 Glazing 50070 Flowers and plants20110 Mechanical contracts 50080 Food and refreshments20120 Metalwork 50090 Household furniture, appliances and goods20130 Painting 50100 Office furniture and equipment20140 Paving 50110 Office supplies and stationery20150 Plumbing 50120 Printing, copying and photographic equipment and supplies

20160 Pre-cast concrete manufacture20170 Pump installation 60000 MISCELLANEOUS GOODS AND SUPPLIES20180 Road works 60010 Environmental cleansing equipment, goods and supplies20190 Sewerage systems and construction 60020 Fire protection equipment, goods and supplies20200 Water works and pipelines 60030 Garden tools

60040 Material and warehousing machinery, equipment and goods

30000 ELECTRICAL AND MECHANICAL EQUIPMENT, SERVICESAND SUPPLIES 60050 Measuring, testing and observation equipment

30010 Bearing supplies 60060 Protective clothing and uniforms30020 Bolts, nuts and fasteners 60070 Security equipment, goods and services30030 Electric cables 60080 Sports and recreational equipment and goods30040 Electrical component supplies30050 Electrical equipment repairs 70000 PROFESSIONAL SERVICES30060 Hardware supplies 70010 Accounting, auditing and management services30070 Lifting equipment 70020 Architectural services30080 Mechanical seals and packing 70030 Consulting engineering-Electrical30090 Pipe and irrigation supplies 70040 Consulting engineering-Environmental30100 Power generation and distribution machinery and accessories 70050 Consulting engineering-Other 30110 Pump spares 70060 Consulting engineering-Project management30120 Small tools 70070 Consulting engineering-Roads and Storm water 30130 Transformer services 70080 Consulting engineering-Sewerage systems30140 Valves, couplings 70090 Consulting engineering-Structures, Buildings, Bridges, etc30150 Water meters, pipes, fittings, PVC, polyethylene, etcetera 70100 Consulting engineering-Water systems

70110 Consulting engineering-Geo-technical40000 GENERAL SERVICES 70120 Consulting engineering-Solid waste40010 Accommodation and lodging 70130 Engineering services

40020 Advertising, communication, design, editorial, publication andmarketing services 70140 Financial services

40030 Auctioneering services 70150 Land surveying40040 Bookkeeping and accounting services 70160 Legal services-contracts40050 Catering and refreshments 70170 Legal services-conveyancing40060 Cleaning services 70180 Legal services-litigation40070 Conferencing facilities and facilitation 70190 Legal services -other 40080 Contract administration 70200 Consulting engineering-Mechanical40090 Courier services 70210 Medical services

40100 Education and training 70220 Project management40110 Environmental impact studies 70230 Quantity surveying40120 Freight forwarding and cleaning services 70240 Town and regional planning40130 General maintenance services40140 Health care 80000 VEHICLE SUPPLY AND TRANSPORTATION SERVICES40150 Horticulture 80010 Alarm and tracking systems40160 Infrastructural maintenance 80020 Batteries40170 Inspection services 80030 Engine overhauls40180 Insurance 80040 Fuel, oils and lubrications40190 IT, broadcasting and telecommunication services 80050 Hydraulics40200 Interior decorating, refurbishment and upholstery 80060 Panel beating40210 Land valuation services 80070 Radiator repairs40220 Laundry and dry-cleaning services 80080 Spares and parts40230 Locksmith services 80090 Towing services40240 Mailing services 80100 Transmissions40250 Management services 80110 Tyres and tubes40260 Miscellaneous equipment and goods hiring 80120 Upholstery40270 Personnel services 80130 Vehicle fleet management40280 Pest control and removal services 80140 Vehicle supply40290 Photographic and graphic design services 80150 Windscreens


5/8

ADD ANY COMMODITIES / SERVICES NOT LISTED AND SUPPLY SPECIFIC ITEMS WITHIN THE MAIN CATEGORIES:


6/8

KREDIET BEVEL INSTRUKSIE / CREDIT ORDER INSTRUCTION /Umyalelo wokutsla imali kulungiselelwa ukufakwa kulowo unetyala kuye

Dit is die Blue Crane Route-munisipaliteitse beleid om alle krediteure deur middelvan direkte bankoorplasings te vereffen.Verskaf meegaande inligting en verkryasb. u bankiers se bevestiging.

It is the policy of the Blue Crane RouteMunicipality to pay all creditors bymeans of direct bank transfers. Pleasecomplete this information and acquireyour bankers confirmation.

Yinkqubo kaMasipala Blue CraneRoute ukuhlawula abo kufunekabebahlawule ngokufaka imaliebhankini.Nceda ke ngoko uzalise oluxwebhu lungezantsi ngeenkcukachazakho ucele ibhanki yakho ukubayenze isiqinisekiso sezi nkcukacha.

BESONDERHEDE VANFIRMA/INSTANSIE: DETAILS OFFIRM/INSTITUTION: IINKCUKACHAZEFEMU/IZIKO

Naam / Name / Igama

Adres / Address / Idilesi

BESONDERHEDE VAN MY/ONSBANKREKENING IS AS VOLG:

DETAILS OF MY/OUR BANK ACCOUNT ARE AS FOLLOWS:

Iinkcukacha zebhanki yam zimingolu hlobo

NAAM VAN BANK / NAME OF BANK / IGAMA LEBHANKI

NAAM VAN TAK / NAME OF BRANCH / IGAMA LESEBE LEBHANKI

TAKKODE / BRANCH CODE / IKHOWUDI YESEBE REKENINGNOMMER / ACCOUNT NUMBER / INOMBOLOYE_AKHAWUNTI TIPE REKENING / TYPE OF ACCOUNT / UHLOBO LWE_AKHAWUNTI 1 = Tjekrekening / Cheque Account / I-akhawunti yetshekhi 2 = Spaarrekening / Savings Account / I-akhawunti yemali egciniweyo

Ek/ons versoek en magtig hiermee die BlueCrane Route munisipaliteit om enige bedrae watmy/ons mag toeval, in my/ons bankrekening tekrediteer.

Ek/ons verstaan dat 'n betalingsadvies deur die

Blue Crane Route munisipaliteit in die normalewyse verskaf sal word wat die datum sal aantoonwanneer die fondse beskikbaar sal wees, asookbesonderhede van die betaling.

Ek/ons onderneem verder om die Blue CraneRoute munisipaliteit vroegtydig in kennis te stelvan enige verandering in my/onsbankbesonderhede en erken dat hierdiemagtiging slegs deur my/ons met dertig daekennis gekanselleer kan word deur middel vanvoorafbetaalde geregistreerde pos.

I/we hereby request and authorise theBlue Crane Route municipality to pay anyamounts that may accrue to me/us to thecredit of my/our bank account.

I/we understand that a payment advice will

be supplied by the Blue Crane Routemunicipality in the normal way that willindicate the date on which funds will beavailable in my/our bank account anddetails of payment.

I/we further undertake to inform the BlueCrane Route municipality in advance of any change in my/our bank details andaccept that this authority may only becancelled by me/us by giving thirty daysnotice by prepaid registered post.

Mna/Thina sicela/sigunyazisa uMasipalaBlue Crane Route ukuba ahlawule yonkeimali eziimfanelo zam/zethu kwi-akhawuntiyebhanki yam/yethu.

Ndi/Siyaqonda ukuba isiqinisekiso semaliehlawulwe ngumasipala siza kufumanekakwaye eso siqinisekiso siza kubonisa umhlaekuhlawulwe ngawo kunye nezinyeiinkcukacha zentlawulo.

Ndi/Siya kumazisa umasipala xa iinkcukachazebhanki yam zitshintshile kwaye ndizakubanika isaziso seentsuku ezingama-30ndisithumele ngeleta erejistarishiweyo.

.... VOORLETTERS EN VAN: GEMAGTIGDE HANDTEKENING: DATUM: TELEFOONNOMMER:INITIALS AND SURNAME: AUTHORISED SIGNATURE: DATE: TELEPHONE NUMBER:

OONOBUMBA BOKUQALA USAYINO OLUGUNYAZISIWEYO UMHLA INOMBOLO YEFOWUNIBEGAMA KUNYE NEFANI

VIR BANKGEBRUIK ALLEENLIK / FOR BANK USE ONLYKUSETYENZISWA YIBHANKI KUPHELA

Ek/ons sertifiseer hiermee dat die besonderhede van ons klint se bankrekening soos aangeduiop die krediet bevel instruksie korrek is:I/we hereby certify that the details of our clients bank account as indicated on the credit order instruction is correct:

-Ndi/Siqinisekisa ukuba iinkcukacha zabaxhasi bethu ezibhalwe kwimiyalelo yokudiphozithaimali ilungile

..........................................................................................................................................................GEMAGTIGDE HANDTEKENING / AUTHORISED SIGNATURE / -Usayino olugunyazisiweyo

AMPTELIKE DATUMSTEMPEL:OFFICIAL DATE STAMP:

-ISITAMPU SOMHLAESISESIKWENI

FOR FULL SUPPLIER ACCREDITATION ALL PARTS MUST BE COMPLETED AND SIGNED:


7/8

DECLARATION BY SUPPLIER 1. This document serves as a declaration to be used by the municipality in ensuring that when goods and

services are being procured, all reasonable steps are taken to combat the abuse of the supply chainmanagement system. No Registration will be accepted from persons in the service of the state *.

2.(a) Any prospective supplier, having a kinship with persons in the service of the state, including a bloodrelationship, may in terms of current legislation register on the Municipality's Database. In view of possibleallegations of favouritism, should a resulting bid, or part thereof, be awarded to suppliers connected with or related to persons in the service of the state, it is required that the supplier or his/her authorisedrepresentative declare their position in relation to the evaluating/adjudicating authority and/or take an oathdeclaring his/her interest.

2.(b) The request for registration on the Municipalitys database may be rejected if the supplier, or any of itsdirectors/members/partners have:(i) abused the municipalitys supply chain management system or committed any improper conduct in relation to such system; (ii) been convicted for fraud or corruption during the past five years;(iii) wilfully neglected, reneged on or failed to comply with any government, municipal or other public sector contract during the past

five years;(iv) being a person whose tax matters are not cleared by the South African Revenue Services; or (v) been listed in the Register for Tender Defaulters in terms of section 29 of the Prevention and Combating of Corrupt Activities Act

(No 12 of 2004).

3.In order to give effect to the above, the following questionnaire must be completed and signed

before a Commissioner of Oaths.

3.1 Print full Name: .

3.2 Company/CC Registration or ID Number: .

3.3 Are you presently in the service of the state? * YES / NO

3.3.1 If so, furnish particulars.

3.4 Have you been in the service of the state for the past twelve months? YES / NO


3.5 Do you, have any relationship (family, friend, other) with persons in the service of the stateand who may be involved with the evaluation and or adjudication of any prospective bid?

YES / NO


3.6 Are you, aware of any relationship (family, friend, other) between a supplier and any personsin the service of the state who may be involved with the evaluation and or adjudication of anybid?

YES / NO


3.7 Are any of your companys directors, managers, principle shareholders or stakeholders inthe service of the state?

YES / NO


3.8 Are any spou se, child or parent of your companys directors, managers, principleshareholders or stakeholders in the service of the state?

YES / NO


3.9 Is the supplier or any of its directors/partners listed on the National Treasurys database as acompany or person prohibited from doing business with the public sector?

YES / NO



8/8

3.10 Is the supplier 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)?

YES / NO


3.11 Was the supplier or any of its directors convicted by a court of law (including a court of lawoutside the Republic of South Africa) for fraud or corruption during the past five years?

YES / NO


3.12 Does the supplier or any of its directors owe any municipal rates and taxes or municipalcharges to the municipality / municipal entity, or to any other municipality / municipal entity,that is in arrears for more than three months?

YES / NO


3.13 Was any contract between the supplier and the municipality / municipal entity or any other organ of state terminated during the past five years on account of failure to perform on or comply with the contract?

YES / NO


CERTIFICATION

I, THE UNDERSIGNED, ..... CERTIFYTHAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS CORRECT. I ACCEPT THAT THESTATE MAY ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE.

. . .. .. Signature Position Date

* 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 an employee of Parliament or a provincial legislature.

Commissioner of Oaths

Signed and sworn to before me at

on this the day of 20 . by theDeponent, who has acknowledged that he/she knows and understandsthe contents of this Affidavit, it is true and correct to the best of his/herknowledge and that he/she has no objection to taking the prescribedoath, and that the prescribed oath will be binding on his/herconscience.

COMMISSIONER OF OATHS:

Position:

Address:

Tel:

Apply official stamp of authority on this page:

1. Bcrm Database Reg Form

Documents

Transcript of 1. Bcrm Database Reg Form