APPLICATION FORM TO REGISTER ON THE SERVICE …

1 APPLICATION FORM TO REGISTER ON THE SERVICE PROVIDER database OF THE department OF rural development AND land reform Page 1 of 32 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.

2 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 . 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.

3 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 Page 2 of 32 SECTION ONE : CONDITIONS Please note that all information will be treated confidentially.

4 Applications that are incomplete or which are not accompanied by the required documents will be disqualified. Completed APPLICATION forms should be posted to or hand delivered at the above mentioned addresses 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 .

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. 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.

6 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. 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 .

7 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 Page 3 of 32 The entity being blacklisted by National Treasury If the entity has acted in an improper, fraudulent or corrupt manner SECTION TWO : SUPPLIER INFORMATION 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 Company Addresses Postal Address Town Region Code Physical Address Town Region Code Company Type (Mark with an X in the applicable column)

8 Public Company Private Company Close Corporation Section 21 Company Trust Partnership Sole Proprietor State Owned Enterprises Non-GovernmentalOrganisation Other If selected other, please specify: _____ Page 4 of 32_____ Contact Person Details Contact Person Full Name Position in Company Identity Number Telephone Number Fax Number E-Mail Address Telephone Number Cell Phone Number Contact Person Addresses Postal Address Town Region Code Physical Address Town Region Code 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.

9 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 Region Town A, Town B Eastern Cape Free State Gauteng Limpopo Kwa-Zulu Natal Mpumalanga Northern Cape Western Cape Northwest Page 5 of 32 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.

10 Name of Company Company Registration Nr Percentage Ownership Page 6 of 32 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.)