APPLICATION FORM TO REGISTER ON THE SERVICE · PDF fileapplication form to register on the...

APPLICATION FORM TO REGISTER ON THE SERVICE PROVIDER DATABASE OF THE DEPARTMENT OF RURAL DEVELOPMENT AND LAND REFORM

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THE FOLLOWING DOCUMENTS/ INFO MUST BE ATTACHED (REQUIREMENTS)

Proof of banking details (Applicants must ensure that the original bank stamp is attached and the bank official must complete the supplier maintenance form/ banking details form. Kindly be advised that the cancelled cheque will not be accepted).

Bank statement.

Operating contact and fax numbers.

Company profile with company letterhead must be attached.

Certified copies of ID (shareholders/ members).

CK1.

Proof of registration for any services/ consultancy that requires registration with professional bodies .e.g. CIBD for construction services, PSIRA for security services and etc.

Valid and original tax clearance certificate (SDB 2)

Declaration of interest (SDB4),

Declaration of bidder’s past supply chain management practices (SDB8)

B-BBEE Status Level of Contribution Certificate

NB: It is recommended that Departments add the following declaration to their Supplier Registration Forms for the Supplier to sign:

For purposes of section 256 of the Tax Administration Act of 2011 (the TAAct), the contractor / service provider authorizes the South African Revenue Service to disclose ‘taxpayer information’ as contemplated under the provisions of Chapter 6 of the TAAct in relation to the compliance status of tax registration, tax debt and filing requirements of.

________________. _______________ _____________

Name of other party here Signature Date

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SECTION ONE : CONDITIONS

1.1 Please note that all information will be treated confidentially.

1.2 Applications that are incomplete or which are not accompanied by the required documents will be disqualified.

1.3 Completed application forms should be posted to or hand delivered at the above mentioned addresses

1.4 The Department of Rural Development and Land Reform’s Service Provider Database will be used mainly for the purposes of identifying entities that can be approached when price quotations for goods and services are to be invited. The fact that an entity is registered as a supplier does not constitute any contractual relationship between that business and the Department of Rural Development and Land Reform.

1.5 For procurement above the financial limit applicable to price quotations, as determined from time to time by National Treasury, the Department Rural Development and Land Reform will normally invite competitive Bids by means of advertisements in the Government Tender Bulletin. The onus is on entities to ensure that they obtain copies of the Bidding documents that are available at the Department of Rural Development and Land Reform when Bids are advertised.

1.6 It is the responsibility of a Registered Entity to inform the Department of Rural Development and Land Reform immediately in writing of any changes in the particulars as stated in the application, especially changes in respect of the BBBEE status of the entity. Should a contract be awarded to an entity as a result of incorrect particulars on the status of an entity, the Department of Rural Development and Land Reform shall have the right to, in addition to any other remedy that it may have in terms of the Preferential Procurement Regulation, cancel the contract and to claim for damages.

1.6 The Department of Rural Development and Land Reform reserves the right to cancel the registration of an entity if that entity has given incorrect or false information in the application form or any correspondence relating to the application:

• Failed to inform the Department Rural Development and Land Reform of any changes of the particulars as furnished in the application

• Failed to comply with the conditions of any contract that might have been awarded to the entity

• Failed to respond on requests for price quotations

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• The entity being blacklisted by National Treasury

• If the entity has acted in an improper, fraudulent or corrupt manner

SECTION TWO : SUPPLIER INFORMATION

2.1 Supplier Details

Registered Name Trading Name Holding Name Company Registration Number Income Tax Registration Number Vat Registration Number Telephone Number Fax Number Cell Phone Number E-Mail Address

2.2 Company Addresses

Postal Address Town Region Code

Physical Address Town Region Code

2.3 Company Type

(Mark with an X in the applicable column)

Public Company Private Company Close Corporation Section 21 Company Trust Partnership Sole Proprietor State Owned Enterprises Non-GovernmentalOrganisation Other

If selected other, please specify: ________________________________________________________

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__________________________________________________________________________________

2.4 Contact Person Details

Contact Person Full Name Position in Company Identity Number Telephone Number Fax Number E-Mail Address Telephone Number Cell Phone Number

2.5 Contact Person Addresses

Postal Address Town Region Code

Physical Address Town Region Code

2.6 Supply Region and Town

Please indicate which province you will be capable of delivering goods or services, and indicate the town names within the region. Goods Service Providers must supply proof of satellite office existence should they wish to link themselves to a region where their main offices are not based or attach proof of Goods delivered previously around the area on other projects.

Regions Mark Towns e.g. Region Town A, Town B Eastern Cape Free State Gauteng Limpopo Kwa-Zulu Natal Mpumalanga Northern Cape Western Cape Northwest

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2.7 Ownership of Company

Full Name Position in Company Identity Number Telephone Number Fax Number E-Mail Address Telephone Number Cell Phone Number Percentage Owned

Please indicate ownership on other Companies with percentage owned.

Name of Company Company Registration Nr Percentage Ownership

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2.8 Commodities

Please indicate on Annexure A (attached), the goods and/or services, in terms of your Core Business you can offer the Department of Rural Development and Land Reform. The main commodity is bolded for your ease of reference.

PLEASE NOTE THAT SERVICE PROVIDERS ARE LIMITED TO THREE (3) COMMODITIES ONLY

ANNEXURE A

Goods Commodity List (The main commodity is bolded for your ease of reference.)

COMMODITIES AND SUB-COMMODITIES TICK

AGRICULTURAL EQUIPMENT AND ACCESSORIES

Agricultural Equipment

Agricultural Accessories

AGRICULTURAL SUPPLIES

Live Animals

Animal Feed

Seeds, Bulbs, Seedlings and Cuttings

Fertilizers, Plant Nutrients and Herbicides

Pest Control Products

AIR CONDITIONING, CIRCULATING AND HEATING EQUIPMENT

Air Conditioner

Air Conditioner Regulator

Air Circulating Ventilator

Fans

Heaters

ACCOMMODATION FURNITURE AND FURNISHINGS

Reception Chairs and Couches

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Benches

Carpet

Blinds and Curtains

Accommodation Furnishings

Outdoor Furniture and Furnishings

Tables

COMMUNICATION EQUIPMENT AND ACCESSORIES

Communication Devices and Accessories

Communication Equipment

COMPUTER HARDWARE AND SOFTWARE

Computer Monitor

Computer Drives and Writers

Computer Accessories

Printers

Printer Accessories

Printer Toner and Cartridges

Memory Devices

Modems and Motherboard

Network, Port, Hub and Accessories

Software

Licenses

Servers and Accessories

BAGS AND CASES

Carry Bags

Cases

Luggage and Travelling Bags

Equipment Cases

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CLEANING EQUIPMENT AND SUPPLIES

Cleaning Equipment

Cleaning Supplies

Hygiene Supplies

Protective Gear

UNIFORM

Ladies Blouse Shirts and T-Shirts

Ladies Trousers and Tracksuits

Ladies Dresses and Skirts

Rain Suite

Men Shirts and T-Shirts

Men Trousers and Tracksuits

Jerseys and Sweater

Jackets and Blazers

Socks, Scarf and Belts

Footwear

Protective Apparel

GROCERIES

Beverages

Bread and Bakery products

Groceries and Vegetables

KITCHEN AND ELECTRICAL APPLIANCES AND SUPPLIES

Kitchen Appliances

Crockery and Cutlery

Kitchen Supplies

OFFICE MACHINES AND EQUIPMENT AND SUPPLIES

Office Machine

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Office Equipment

Office Supplies

OPTICAL AND NAVIGATIONAL EQUIPMENT

Optical Equipment

Navigation Equipment

MEDICAL EQUIPMENT AND SUPPLIES

Medical Equipment

Medical Supplies

OFFICE FURNITURE AND FURNISHINGS

Desks

Chairs

Credenzas

Cupboard and Bookcase

Drawers

Cabinets and Filing Cabinet

Bulk Filing Unit

Steel Factory Lockers

Boardroom Tables

Office Furnishings

Tables and Counter Tops

Wall Units

PHOTOGRAPHIC, PRINTING AND PRESENTATION EQUIPMENT AND SUPPLIES

Printing and Publishing Equipment

Audio and Visual Presentation and Composing Equipment

Photographic or Filming or Video Equipment

Photographic and Recording Media

Photographic Filmmaking Supplies

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PROMOTIONAL ITEMS AND GIFTS

Corporate Gifts

Promotional Items

Displays and Stands

PUBLISHED PRODUCTS

Printed Media

Electronic Reference Material

Signage and Accessories

PROPERTY, LAND AND TEMPORARY SHELTER

Prefab House

Mobile House

Shelter

Land

Fixed Property

RECREATIONAL AND SPORTING EQUIPMENT AND ACCESSORIES

Sports Equipment and Accessories

Sports Kit

SAFETY AND SECURITY EQUIPMENT AND ACCESSORIES

Safety Equipment

Security Accessories

Alarm and Security Systems

Locks and Handles

STATIONERY

Book, Pads and Legal

Boards and Flip Charts

Boards and Flip Charts Consumables

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Correction Fluids and Tape

Desktop Stationery

Envelopes and Packaging

Filing and Storage

File Dividers and Indexes

Glue, Labels and Tapes

Markers and Highlighters

Paper and Board

Pens and Refills

Pencil, Clutch and Refills

Punches and Staplers

Staples and Staple Remover

Stamps

Stamp Pad and Ink

Graphic and Technical Drawing

TOOLS AND GENERAL EQUIPMENT

Hand Tools

Electrical Tools

General Equipment

Garden Equipment

MAINTENANCE SUPPLIES AND ACCESSORIES

Electrical Supplies

Plumbing Supplies

General Maintenance Supplies and Accessories

SURVEYING AND MEASURING TOOLS

Surveying Tools

Measuring Tools

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Services Commodity List

AUCTIONEER SERVICES

Live Stock Auction

Vehicle Auction

Property Auction

Furniture Auction

House Auction

AGRICULTURAL SUPPORT

Participatory Situation Analysis

Land Resource Assessment / Feasibility Study

Farm Management Development and Support

Farm Management Planning

Agricultural Economic Support

Agricultural Extension and Training Support

Agricultural Engineering Support

Training in Extension Services for Farming

Agricultural Advisory Services

CLEANING SERVICES (CERTIFICATION REQUIRED)

General Building Cleaning Services Interior

General Building Cleaning Services Exterior

Hygiene Services

Carpet Cleaning Services

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Garden and Plant Maintenance Services

Vehicle Cleaning Services

Waste Management Services

COMMUNITY SUPPORT / PROJECT SUPPORT

Legal Entity Establishment

Mediation and Conflict Resolution

Land Reform Project Facilitation, Community Surveying and Scoping (RLCC)

Beneficiary Verification

Institutional Development and Capacitation

Project Management

CONSTRUCTION SERVICES (CIDB CERTIFICATION REQUIRED)

Structural – VIP Toilets, Houses

Building – Including Material

Civil – Roads, Bridges

Mechanical - Engineers

Fencing – Including Material and Installation

Structural Renovation

EQUIPMENT HIRE

Catering Equipment

Construction Equipment

Earthmoving Equipment

General Equipment

Tents and Marques

EDUCATION AND TRAINING SERVICES (CERTIFICATION REQUIRED)

Professional Training

Alternative Educational Systems

Educational Institutions

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Specialized Educational Services

GENERAL BUILDING MAINTENANCE AND REPAIR SERVICES (CERTIFICATION REQUIRED)

Locksmith Services

Partitioning Services

Window Services

Fumigation Services

Pest Control Services

Electrical Services

Plumbing Services

HEALTH SERVICES

Wellness Services

INTERIOR DECORATING AND HOUSEHOLD SERVICES

Dry Cleaning and Laundry Services

Upholstery Services

Floor Ware Installation Services

Interior Decorating Services

Installation Services of Curtains and Blinds

Wall Ware Services

INFORMATION TECHNOLOGY SERVICES

Installation Services

Specialized IT Services

Hardware Repairs and Maintenance Services

Data Management and Backup Services

Upgrades and Maintenance

G.I.S – System Design

Database Development and Design

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LAND TENURE SPECIALISTS

Rights Enquiries

Act Commissioners

LEASE OF EQUIPMENT AND MACHINE

Beverage Vending Machine

Photocopy Machine

Water Coolers

LOGISTICAL SERVICES

Catering Services

Exhibition Centre and Meeting Facilities

Event Management Services

MANAGEMENT AND BUSINESS PROFESSIONALS AND ADMINISTRATIVE SERVICES (CERTIFICATION REQUIRED)

Management Advisory Services

Subscriptions Services

Real Estate Services

Marketing and Distribution Services

Policy Development and Management Services

Document and Information Management Services

Business Administration Services

MONITORING AND EVALUATION

Land Reform Programme Management M&E

Project Monitoring and Evaluation

Organisational Monitoring and Evaluation

Diagnostic Evaluation Studies

Indicator Portocols

Monitors and Evaluation Software

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HUMAN RESOURCES SERVICES

Human Resources Development Services

Human Resources Management Services

LEGAL SERVICES (CERTIFICATION REQUIRED)

Conveyancing

Notaries / Notary Public

Land Legal Specialist

Land Reform Law Specialist

Land Reform Mediator

BUSINESS PLAN

Business Plan (RLCC)

Business Plan (PLRO)

AUDITING SERVICES (CERTIFICATION REQUIRED)

Financial and operational Audit

Forensic and Investigation Audit

Information Technology Forensic Audit

Information technology Audit

Legal Compliance Audit

Performance Management Audit

FINANCIAL SERVICES (CERTIFICATION REQUIRED)

Business and Financial Advisory Services

Finance Systems Designing Services

Charted Accounts Services

VALUATIONS

Agricultural / Rural

Urban and Commercial / Industrial

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Property Assessors

LAND MANAGEMENT SUPPORT

Farm / Property Management On-Site

Lease Management

State Land Issues

Audit on State Land

Land Use Investigation

LAND REFORM SERVICES

Land Development Planning Services

Land Reform, Restitution, Redistribution and Land Tenure Programme Services

Agricultural Support and Technical Project Support Services

Institutional and Social Development Services - LR Programme

LAND SURVEYING (CERTIFICATION REQUIRED)

Land Surveyors

PUBLICATIONS, COMMUNICATION AND INFORMATION SERVICES

Advertising on newspapers

Publications

Writing and Translations Services

Printing and Reproduction Services

Photographic Services

Graphic Design Services

PANEL SERVICES

Project Panel

REGIONAL AND INTEGRATED RURAL DEVELOPMENT PLANNING

Regional and Integrated Rural Development Planning

Township Establishment

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Engineering Support

Environmental Impact Assessment / Environmental Scoping

Land Use Planning (RLCC)

RELOCATION, REMOVALS AND STORAGE, TRANSPORTATION AND MAIL SERVICES

Mail and Cargo Transport

Bus and Public Transport

Office Furniture and Household Relocation, Removal and Storage

Distribution and Delivery Services

Chauffer and Shuttle Services

Transportation or Moving of Livestock Services

SECURITY AND SAFETY SERVICES (CERTIFICATION REQUIRED)

Security and Personal Safety

Security Surveying Services

TELECOMMUNICATION SERVICES

Telecommunication Installation

Telecommunication Maintenance and Repairs

SERVICES AND REPAIRS

Service and Repairs of Office Machine

Service and Repairs of Furniture

Service and Repairs of Equipment

WATER PROVISION (CERTIFICATION REQUIRED)

Water Provision Contractors / Consultants

Borehole Construction

NB: Entities are free to supply details of any other products or services they render which are not included on the above lists.

………………………………………………………………………………………………………………………..

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2.9 References

Please list contracts/assignments completed by your company in the last three (3) years in relation to the commodities you linked your company to.

Work Performed Client Contact Person and Telephone Number

3. DECLARATION

I/ We the undersigned:

Declare that the information supplied/ provided (including any attachments) is complete and correct to the best of my/ our knowledge. I/ We understand that any false information supplied could lead to my/ our application being disqualified.

-------------------------------------------------- ----------------------------------------

SIGNATURE OF OWNER OR AUTHORIZED DATE

REPRESENTATIVE

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SECTION FOUR : OFFICE LIST FOR DATABASE DEVELOPMENT

OFFICE PHYSICAL ADDRESS CONTACT NUMBERS 1 PSSC: KwaZulu Natal 270 Jabu Ndlovu Street,

Pietermaritzberg 033 264 9500/6546

2 PSSC: Eastern Cape Block H, Ocean Terrace Quigney, East London

043 743 0078

3 PSSC: Western Cape 14 Long Street, 3rd Floor, Cape Town

021 658 4300/4482

4 PSSC: Free State SA Eagle Building,136 Maitland Street, Bloemfontein

051 447 8465/ 6140

5 PSSC: Northern Cape Corner Knight and Stead Street 6th Floor New Public Building, Kimberley

053 830 4000/4041

6 Mpumalanga Provincial Land Reform Office

18 Bell Street , Bell Tower Building, Nelspruit

013 755 3499

7 Mpumalanga Regional Land Claims Commission

30 Samora Machel Drive, Restitution House, Nelpruit 1200

013 756 6093/6088

8 Limpopo Provincial Land Reform Office

Andria Building, Second floor, Cnr Schoeman and Rissik Street, Polokwane

015 297 3539

9 Limpopo Regional Land Claims Commission

Kagiso House, Cnr Schoeman & Rissik Street, Polokwane

015 284 6300

10 PSSC: North West Shama Investment Building 9 Shippard Street, Mafikeng, 2745

018 397 9700

11 North West Regional Land Claims Commission

Unit 4 Batlhaping Street, Mmabatho

018 389 9600/9620

12 PSSC: Gauteng 1145 Burnett Street, Hatfield, Pretoria 0025

012 432 4200

13 Gauteng Regional Land Claims Commission

9 Bailey Lane, Arcadia, Pretoria

012 310 6500/6526

14 Head Office 184 Jeff Masemola Street, Old Building, Room 14D, Pretoria

012 312 9864/9463/9847

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PW1423

BAS PMIS LOGIS WCS

OFFICE: ……………………………

The Director General : National TreasuryDept Of Rural Development and Land ReformI/We hereby request and authorise you to pay any amounts, which may accrue to me/us to the credit

of my/our account with the mentioned bank.

I/we understand that the credit transfers hereby authorised will be processed by computer through a system

known as "ACB - Electronic Fund Transfer Service", and I/we understand that not additional advice of payment

will be provided by my/our bank, but that the details of each payment will be printed on my/our bank statement

or any accompanying voucher. (This does not apply where it is not customary for banks to furnish bank

statements).

I/we understand that the Department will supply a payment advice in the normal way, and that it will indicate

the date on which the funds will be made available on my/our account.

This authority may be cancelled by me/us by giving thirty days notice by prepaid registered post. Please ensure information is validate as per required bank screens .

I/We understand that bank details provided should be exactly as per the records held by the bank.

I/We understand that the Department will not assume responsibiliy for any delayed payments, as a result of

incorrect information supplied.

Trading Name

Tax Number

VAT Number

First Name:

Surname:

Street Address

Postal Code

New Supplier information Update Supplier information

Supplier Type: Individual Department Partnership

Company Trust

CC Other ( Specify )

Department Number

New Detail

SUPPLIER MAINTENANCE:

CONTRACTOR

CONSULTANT

Payment Address

Address Detail

Company / Personal Details

Registered Name

Title:

Initials:

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PW1423

(This field is comulsory and should be completed by a bank official from the relevant bank).

Account Number

Branch Name

Branch Number

Cheque Account

Savings Account

Transmission Account

Bond Account

Other (Please Specify)

ID Number

Passport Number

Company Registration Number

*CC Registration

*Please include CC/CK where applicable

Practise Number

Bank stamp

It is hereby confirmed that this details have been verified

against the following screens

ABSA-CIF screen

FNB-Hogans system on the CIS4

STD Bank-Look-up-screen

Nedbank- Banking Platform under the Client Details Tab

Business

Area Code Telephone Number Extension

Home

Area Code Telephone Number Extension

Fax

Area Code Fax Number

Cell

Cell Code Cell Number

Email Address

Adresss of Rural Development and Land Reform

Office where form is submitted from:

/ / / /Date (dd/mm/yyyy) Date (dd/mm/yyyy)

NB: All relevant fields must be completed

When the bank stamps this

entity maintenenace form they

confirm that all the

information completed by the

entity is correct.

Account Type

Account Name

Supplier Account Details

Rank

Contact Details

Contact Person:

Supplier Signature Regional Office Sender

Print Name Print Name

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SBD 2

TAX CLEARANCE CERTIFICATE REQUIREMENTS

It is a condition of bid that the taxes of the successful bidder must be in order, or that satisfactory arrangements have been made with South African Revenue Service (SARS) to meet the bidder’s tax obligations. 1 In order to meet this requirement bidders are required to complete in full the attached form TCC 001

“Application for a Tax Clearance Certificate” and submit it to any SARS branch office nationally. The Tax Clearance Certificate Requirements are also applicable to foreign bidders / individuals who wish to submit bids.

2 SARS will then furnish the bidder with a Tax Clearance Certificate that will be valid for a period of 1 (one) year

from the date of approval. 3 The original Tax Clearance Certificate must be submitted together with the bid. Failure to submit the original

and valid Tax Clearance Certificate will result in the invalidation of the bid. Certified copies of the Tax Clearance Certificate will not be acceptable.

4 In bids where Consortia / Joint Ventures / Sub-contractors are involved, each party must submit a separate

Tax Clearance Certificate. 5 Copies of the TCC 001 “Application for a Tax Clearance Certificate” form are available from any SARS branch

office nationally or on the website www.sars.gov.za. 6 Applications for the Tax Clearance Certificates may also be made via eFiling. In order to use this provision,

taxpayers will need to register with SARS as eFilers through the website www.sars.gov.za. Jeyrel:\Mdk416-SBD2 tax clearance

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TCC 001 TAX CLEARANCE

Application for a Tax Clearance Certificate

Name/Legal name(Initials & Surname or registered name)

Surname

Particulars of applicant

Purpose

Particulars of representative (Public Officer/Trustee/Partner)

Trading name (if applicable)

First names

VAT registration no

Customs code

Income Tax ref no

Income Tax ref no

PAYE ref no

SDL ref no

UIF ref no

Page 1 of 2

ID/Passport no

ID/Passport no

Company/Close Corp. registered no

4

7

L

U

Telephone no

Telephone no

Physical address

Physical address

Postal address

E-mail address

E-mail address

Fax no

Fax no

C O D E

C O D E

N U M B E R

N U M B E R

C O D E

C O D E

N U M B E R

N U M B E R

If “Good standing”, please state the purpose of this application

Select the applicable option Tenders Good standing

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Particulars of the 3 largest contracts previously awarded

Particulars of tender (If applicable)

Audit

Date started

I the undersigned confirm that I require a Tax Clearance Certificate in respect of Tenders or Goodstanding.

I hereby authorise and instruct to apply to and receive from SARS the applicable Tax Clearance Certificate on my/our behalf.

Appointment of representative/agent (Power of Attorney)

Date finalised Principal Contact person Telephone number Amount

Name of representative/ agent

Name of applicant/ Public Officer

Signature of representative/agent

Signature of applicant/Public Officer

Date

Date

Expected duration of the tender

Estimated Tender amount

Are you currently aware of any Audit investigation against you/the company?If “YES” provide details

Tender number

R ,

year(s)

C C Y Y

C C Y Y

M M

M M

D D

D D

YES NO

Notes:

1. It is a serious offence to make a false declaration.

2. Section 75 of the Income Tax Act, 1962, states: Any person who

(a) fails or neglects to furnish, file or submit any return or document as and when required by or under this Act; or

(b) without just cause shown by him, refuses or neglects to-

(i) furnish, produce or make available any information, documents or things;

(ii) reply to or answer truly and fully, any questions put to him ...

As and when required in terms of this Act ... shall be guilty of an offence ...

3. SARS will, under no circumstances, issue a Tax Clearance Certificate unless this form is completed in full.

4. Your Tax Clearance Certificate will only be issued on presentation of your South African Identity Document or Passport (Foreigners only) as applicable.

Declaration

I declare that the information furnished in this application as well as any supporting documents is true and correct in every respect.

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SBD 4

DECLARATION OF INTEREST

1. Any legal person, including persons employed by the state¹, or persons having a kinship with persons

employed by the state, including a blood relationship, may make an offer or offers in terms of this invitation to bid (includes a price quotation, advertised competitive bid, limited bid or proposal). In view of possible allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons employed by the state, or to persons connected with or related to them, it is required that the bidder or his/her authorised representative declare his/her position in relation to the evaluating/adjudicating authority where-

- the bidder is employed by the state; and/or - the legal person on whose behalf the bidding document is signed, has a relationship with

persons/a person who are/is involved in the evaluation and or adjudication of the bid(s), or where it is known that such a relationship exists between the person or persons for or on whose behalf the declarant acts and persons who are involved with the evaluation and or adjudication of the bid.

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

submitted with the bid. 2.1 Full Name of bidder or his or her representative: …………………………………………………………. 2.2 Identity Number: ………………………………………………………………………………………………… 2.3 Position occupied in the Company (director, trustee, shareholder²): …………………………………….. 2.4 Company Registration Number: ………………………………………………………………………..……. 2.5 Tax Reference Number: ………………………………………………………………………………….……… 2.6 VAT Registration Number: ………………………………………………………………………………....

2.6.1 The names of all directors / trustees / shareholders / members, their individual identity numbers, tax

reference numbers and, if applicable, employee / persal numbers must be indicated in paragraph 3 below.

¹“State” means – (a) 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); (b) any municipality or municipal entity; (c) provincial legislature; (d) national Assembly or the national Council of provinces; or (e) Parliament. ²”Shareholder” means a person who owns shares in the company and is actively involved in the management of the enterprise or

business and exercises control over the enterprise.

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2.7 Are you or any person connected with the bidder YES / NO presently employed by the state? 2.7.1 If so, furnish the following particulars:

Name of person / director / trustee / shareholder/ member: ……....……………………………… Name of state institution at which you or the person connected to the bidder is employed : ……………………………………… Position occupied in the state institution: ……………………………………… Any other particulars: ………………………………………………………………

……………………………………………………………… ………………………………………………………………

2.7.2 If you are presently employed by the state, did you obtain YES / NO

the appropriate authority to undertake remunerative work outside employment in the public sector?

2.7.2.1 If yes, did you attached proof of such authority to the bid YES / NO

document? (Note: Failure to submit proof of such authority, where applicable, may result in the disqualification of the bid.

2.7.2.2 If no, furnish reasons for non-submission of such proof:

……………………………………………………………………. ……………………………………………………………………. …………………………………………………………………….

2.8 Did you or your spouse, or any of the company’s directors / YES / NO trustees / shareholders / members or their spouses conduct business with the state in the previous twelve months?

2.8.1 If so, furnish particulars:

………………………………………………………………….. ………………………………………………………………….. …………………………………………………………………...

2.9 Do you, or any person connected with the bidder, have YES / NO any relationship (family, friend, other) with a person employed by the state and who may be involved with the evaluation and or adjudication of this bid?

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2.9.1If so, furnish particulars. ……………………………………………………………... …………………………………………………………..….

………………………………………………………………

2.10 Are you, or any person connected with the bidder, YES/NO aware of any relationship (family, friend, other) between

any other bidder and any person employed by the state who may be involved with the evaluation and or adjudication of this bid?

2.10.1 If so, furnish particulars.

……………………………………………………………… ……………………………………………………………… ………………………………………………………………

2.11 Do you or any of the directors / trustees / shareholders / members YES/NO

of the company have any interest in any other related companies whether or not they are bidding for this contract?

2.11.1 If so, furnish particulars: ……………………………………………………………………………. ……………………………………………………………………………. …………………………………………………………………………….

3 Full details of directors / trustees / members / shareholders. Full Name Identity

Number Personal Tax Reference Number

State Employee Number / Persal Number

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4 DECLARATION

I, THE UNDERSIGNED (NAME)………………………………………………………………………

CERTIFY THAT THE INFORMATION FURNISHED IN PARAGRAPHS 2 and 3 ABOVE IS CORRECT. I ACCEPT THAT THE STATE MAY REJECT THE BID OR ACT AGAINST ME IN TERMS OF PARAGRAPH 23 OF THE GENERAL CONDITIONS OF CONTRACT SHOULD THIS DECLARATION PROVE TO BE FALSE. ………………………………….. ..…………………………………………… Signature Date …………………………………. ……………………………………………… Position Name of bidder

May 2011

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SBD 8

DECLARATION OF BIDDER’S PAST SUPPLY CHAIN MANAGEMENT

PRACTICES

1 This Standard Bidding Document must form part of all bids invited. 2 It serves as a declaration to be used by institutions in ensuring that when goods

and services are being procured, all reasonable steps are taken to combat the abuse of the supply chain management system.

3 The bid of any bidder may be disregarded if that bidder, or any of its directors

have-

a. abused the institution’s supply chain management system; b. committed fraud or any other improper conduct in relation to such system; or c. failed to perform on any previous contract.

4 In order to give effect to the above, the following questionnaire must be completed and submitted with the bid.

Item Question Yes No 4.1 Is the bidder or any of its directors listed on the National Treasury’s Database of

Restricted Suppliers as companies or persons prohibited from doing business with the public sector? (Companies or persons who are listed on this Database were informed in writing of this restriction by the Accounting Officer/Authority of the institution that imposed the restriction after the audi alteram partem rule was applied). The Database of Restricted Suppliers now resides on the National Treasury’s website(www.treasury.gov.za) and can be accessed by clicking on its link at the bottom of the home page.

Yes

No


4.2 Is the bidder 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)? The Register for Tender Defaulters can be accessed on the National Treasury’s website (www.treasury.gov.za) by clicking on its link at the bottom of the home page.

Yes

No


4.3 Was the bidder 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?

Yes

No


4.4 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?

Yes

No

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http://www.treasury.gov.za/

http://www.treasury.gov.za/


SBD 8

CERTIFICATION

I, THE UNDERSIGNED (FULL NAME)…………………………………………………

CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS TRUE AND CORRECT.

I ACCEPT THAT, IN ADDITION TO CANCELLATION OF A CONTRACT,

ACTION MAY BE TAKEN AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE.

………………………………………... ………………………….. Signature Date

………………………………………. ………………………….. Position Name of Bidder

Js365bW

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