APPLICATION FOR REGISTRATION ON THE …

1 APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database THE SOUTH AFRICAN NATIONAL ROADS AGENCY LIMITED SOC (SANRAL) APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION DESCRIPTION: APPLICATION TO BE REGISTERED ON THE supplier DATABASE / LIST OF PROSPECTIVE SERVICE PROVIDERS THIS DOCUMENT COMPILED BY: THE SOUTH AFRICAN NATIONAL ROADS AGENCY SOC LTD BLOCK C, SOUTHERN LIFE GARDENS 70 2nd AVENUE NEWTON PARK PORT ELIZABETH 6001 Tel No.: (041) 398 3200 E-mail: APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database 1. INTRODUCTION AND GUIDELINES The purpose of this database is to give all prospective suppliers an equal opportunity to submit quotations to SANRAL Southern Region in order to comply with the procedures set out in the Public Finance Management Act 1 of 1999 (PFMA), the Preferential Procurement Policy Framework Act 5 of 2000 (PPPFA), and Supply Chain Management Regulations issued by the National Treasury.

2 Preference will be given to registered suppliers but it does not necessarily follow that suppliers who are not yet registered will be totally excluded from quoting for the supply of goods or service to SANRAL Southern Region Office. APPLICATION FOR REGISTRATION ON SANRAL S SUPPLIERS DATABASE THESE FORMS MUST BE COMPLETED AND SUBMITTED TO: SANRAL SOUTHERN REGION BLOCK C, SOUTHERN LIFE GARDENS 70 2nd AVENUE NEWTON PARK PORT ELIZABETH 6001 OR POSTED TO: PO BOX 27230 GREENACRES 6057 ENQUIRIES: TEL NO.: (041) 398 3200 FOR OFFICIAL USE ONLY NAME OF supplier REGISTRATION NUMBER / VENDOR NUMBER DATE APPROVED APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database APPLICATION FORM 1 IMPORTANT NOTES To be completed by all vendors seeking REGISTRATION as an approved supplier ; The questionnaire must be completed in full and be signed; A company profile may accompany the REGISTRATION form but will not be accepted as substitute for the APPLICATION form all fields on APPLICATION form MUST be completed by applicant; Applicants will be contacted via email and must therefore submit an operating email address.

3 Failure to comply will result in excluding the supplier from the data base; It should be noted that SANRAL reserves the right to accept or reject any APPLICATION without being obliged to give any reasons in this respect; Suppliers will be notified whether APPLICATION was accepted; supplier must comply with all the REGISTRATION criteria for REGISTRATION to be finalized - failure to do so may result in the APPLICATION being declined; Failure to submit all required documents will lead to supplier not being registered on the database. CHECKLIST OF DOCUMENTS REQUIRED NO DOCUMENT REQUIRED RECEIVED YES/NO 1. Completed, Signed & Commissioned supplier Database Form 2. Completed and Signed SBD 4: Declaration of Interests 3. Completed and Signed SBD : Preference Points Claim Form 4. Completed and Signed SBD 8: Bidder s Past SCM Practices 5. Completed and Signed SBD 9: Certificate Of Independent Bid Determination 6. Valid & Original Tax Clearance Certificate 7.

4 Valid BBBEE Verification Certificate 8. Certified Proof of Company REGISTRATION 9. Company Profile 10. Vendor APPLICATION Form APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database 1. BUSINESS PARTICULARS Name Of Business As Registered With The Registrar Of Companies/Close Corporations Business REGISTRATION number: NB: Attach copy of business REGISTRATION certificate Service provider s core business (what is the principle business) VAT REGISTRATION number: NB: Attach Original Tax Clearance Certificate Tax Clearance Certificate Expiry Date Income Tax Reference Number: Postal Address: Physical Address: Postal Code Postal Code Telephone No: Fax No: Cell. No. E-Mail Address: Contact Person: APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database Name of person authorised for signing: Capacity under which the APPLICATION is signed: Date signed: Signature: 2.

5 Please indicate (X) the geographical areas where your business has offices. Please provide addresses, telephone numbers and contact person for different offices (add separate sheet, if necessary) Regions Mark ( X ) Gauteng Kwazulu Natal Western Cape Eastern Cape 3. supplier Group Detail: Type of Firm (Please tick the relevant box) 1 Public Company (Ltd) 2 Private Company ((Pty) Ltd) 3 Closed Corporation (CC) 4 Other (Specify) 5 Joint Venture 6 Sole Proprietor 7 Partnership 8 Trust 9 Section 21 Company 10 Government / Parastatals 4. Range of services offered in relation to the principal business of the enterprise 5. Are you registered with a professional body for the services that you provide? YES NO APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database If so, please state particulars: Name of Organisation Contact Person Telephone number Membership number Date of membership 6.

6 BEE INFORMATION % Of BEE Ownership Provide BEE verification certificate( (from ABVA accredited verification agencies) NB: Attach BEE certificate 7. PREVIOUS EXPERRIENCE / TRACK RECORD List the most important contracts/assignments completed by your firm in the last three years. Service provider s Relevant Experience minimum 3 years public sector experience. WORK PERFORMED FOR WHOM CONTACT PERSON AND TELEPHONE NUMBERS 8. SUPPLIERS OF THE FOLLOWING PRODUCTS/SERVICES ARE REQUIRED TO REGISTER ON THE DATABASE. PLEASE MARK THE MAIN SERVICES YOUR COMPANY SUPPLIES: TYPE SERVICES / GOODS TICK RELEVANT BOX SUPPLIERS Office Stationery Office Furniture Office Equipment Office Groceries Other Office Supplies (crockery, cutlery, etc.) SERVICES Catering Services Printing & Binding Shuttle Services Florists HEALTH AND SAFETY Fire Extinguishers First Aid Supplies OTHER SERVICES General Repairs (Handyman) Cleaning products APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database 9.)

7 TEAM STRUCTURE Personnel Complement (Add separate sheet to list all personnel) No First Name Surname Male/Female Position Accreditation Relevant Experience(years) Geographical Location where service is available APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database SBD 4 DECLARATION OF INTEREST 1. Any legal person, including persons employed by the state , 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.

8 2. In order to give effect to the above, the following questionnaire must be completed and submitted with the bid. Full Name of bidder or his or her representative: .. Identity Number: .. Position occupied in the Company (director, trustee, shareholder ): .. Company REGISTRATION Number: .. Tax Reference Number: .. VAT REGISTRATION Number: .. 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. 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.

9 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. Are you or any person connected with the bidder YES / NO presently employed by the state? APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database 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: .. 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? 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.)

10 If no, furnish reasons for non-submission of such proof: .. 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? If so, furnish particulars: .. 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? If so, furnish particulars.. APPLICATION FOR REGISTRATION ON THE supplier DATABASE OF SANRAL SOUTHERN REGION supplier Database 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? If so, furnish particulars.. 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?