SMMEs and Historically Disadvantaged Individuals with expertise are particularly encouraged to apply.
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, cancelled cheque with original bank stamp attached in the supplier maintenance form will also be accepted).
� Confirmation letter from the bank/ Bank statement.
� Operating contact and fax numbers.
� Company profile with company letterhead must be attached.
� Certified copies of ID (shareholders/ members).
� CK1.
� Valid and original tax clearance certificate.
� 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.
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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 HDI equity ownership and the SMME status of the entity. Should a contract be awarded to an entity as a result of incorrect particulars on HDI/SMME status of that 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 Regulations, cancel the contract and to claim damages.
1.7 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
• The entity being blacklisted by National Treasury
• If the entity has acted in an improper, fraudulent or corrupt manner
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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 Parastatal Non Governmental Organisation 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 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.
Please note that Service Providers are Limited to Three (3) Commodities
ANNEXURE A
Goods Commodity List
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
Benches
Carpet
Blinds and Curtains
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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
Cleaning Equipment and Supplies
Cleaning Equipment
Cleaning Supplies
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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
Office Equipment
Office Supplies
Optical and Navigational Equipment
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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
Promotional Items and Gifts
Corporate Gifts
Promotional Items
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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
Correction Fluids and Tape
Desktop Stationery
Envelopes and Packaging
Filing and Storage
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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
Garden and Plant Maintenance Services
Vehicle Cleaning Services
Waste Management Services
Community Support / Project Support
Legal Entity Establishment
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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
Specialized Educational Services
General Building Maintenance and Repair Services (Certification Required)
Locksmith Services
Partitioning Services
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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
Land Tenure Specialists
Rights Enquiries
Act Commissioners
Lease of Equipment and Machine
Beverage Vending Machine
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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
Human Resources Services
Human Resources Development Services
Human Resources Management Services
Legal Services (Certification Required)
Conveyancing
Notaries / Notary Public
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Land Legal Specialist
Land Reform Law Specialist
Land Reform Mediator
Business Plan
Business Plan (RLCC)
Business Plan (PLRO)
Auditing Services (Certification Required)
Financial Services (Certification Required)
Business and Financial Advisory Services
Finance Systems Designing Services
Charted Accounts Services
Valuations
Agricultural / Rural
Urban and Commercial / Industrial
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
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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
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
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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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2.8 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
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SECTION THREE : HDI AND SMME DECLARATION
3.1 Equity Ownership
Please indicate in %, shares owned by the following groups: (Compulsory)
Group Male Female Disabled Black Coloured Indian White
3.2 BEE
Please indicate the Management structure in % of the total percentage owned.
Group Percentage Owned African Coloured Indian
3.3 HDI Ownership
Historically Disadvantaged Individuals (HDI) Women Equity (WE) Disabled Individuals (DI)
3.4 BBBEE
Has your company been assessed for BBBEE? (Yes/No) Which assessment company has provided your company with your BBBEE rating?
What is your BBBEE rating? Please attach copy of Certificate (Is Certificate attached?)
3.5 SMME Status
(Mark with an X in the applicable column)
Micro Small Medium Large
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3.6 Declaration
I/We the undersigned declare that:
1. The information furnished is true and correct 2. The Equity Ownership claimed is in accordance with the General Conditions
___________________________ _________________________
Signature of Owner or Authorised Date
Representative
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SECTION FOUR : OFFICE LIST FOR DATABASE DEVELOPMENT
4.1
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 Van der sterr Bulding, Rhodes Avenue, Mowbray
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
Home Affairs Building 4th Floor Cnr Henshall & Andrew Street, 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
11 Limpopo Regional Land Claims Commission
Kagiso House, Cnr Schoeman & Rissik Street, Polokwane
015 284 6300
12 PSSC: North West Shama Investment Building 9 Shippard, Mafikeng
018 397 9700
13 North West Regional Land Claims Commission
ABSA Building, Ground Floor, Cnr Provident & University Drive, Mmabatho
018 389 9600/9620
14 PSSC: Gauteng 1145 Burnett Street, Hatfield, Pretoria 0025
012 432 4200
15 Gauteng Regional Land Claims Commission
9 Bailey Lane, Arcadia, Pretoria 012 310 6500/6526
16 Head Office 184 Jacob Mare Street, Old Building, Room 14D, Pretoria
012 312 9786/9863
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