COEGA DEVELOPMENT CORPORATION …

1 COEGA Contact Centre, Cnr Alcyon Rd and Zibuko Street, Zone 1, COEGA IDZ 6001 COEGA Contact Centre, Private Bag X6009, Port Elizabeth 6100 Tel: 08610 26342 Email: Page 1 of 5 Rev 7 26/01/2014 COEGA DEVELOPMENT CORPORATION Application for Database Registration Important Notes: Compulsory documents to accompany the application form are:- 1. Certified copy of the Company registration documents and ID documents of owner/s; 2. Proof address of the Company (Electricity Account or letter from Council/Local Chief) 3. Valid BBBEE Verification Certificate from a SANAS Accredited Verification Agency, or from an Approved Registered Auditor by Independent Regulatory Board of Auditors (IRBA). The Exempted Micro Enterprises (EME), formerly referred to as SMMEs, are expected to submit a letter from the business s Accounting Officer confirming the company turnover of the business is less than 5 million 4. Valid Original SARS Tax Clearance Certificate.

2 5. Active CIDB Registration Declaration and Undertaking:- 1. I am aware that this is an application to be registered on the database of COEGA DEVELOPMENT CORPORATION (CDC) and that the final approval of the application rests with the CDC. 2. I undertake to update the company s registration details on an annual basis. 3. Failure to submit the required documentation will delay the supplier being registered on the database. Duly authorized to sign on behalf of the company:- Signature: Name and Surname: Date: COEGA Contact Centre, Cnr Alcyon Rd and Zibuko Street, Zone 1, COEGA IDZ 6001 COEGA Contact Centre, Private Bag X6009, Port Elizabeth 6100 Tel: 08610 26342 Email: Page 2 of 5 Rev 7 26/01/2014 BUSINESS DETAILS Business Trading Name Business Legal Name Holding Company (if applicable) Company Registration No VAT Registration Number CIDB Registration Number (if applicable) CIDB Grade BBBEE Level BBBEE Expiry Date BBBEE Category Business Categories Annual Turnover Select one category Exempted Micro Enterprise (EME) Less than R5m Qualifying Small Enterprise (QSE) Between R5m R35m Generic Enterprise Above R35m COEGA Contact Centre, Cnr Alcyon Rd and Zibuko Street, Zone 1, COEGA IDZ 6001 COEGA Contact Centre, Private Bag X6009, Port Elizabeth 6100 Tel: 08610 26342 Email.

3 Page 3 of 5 Rev 7 26/01/2014 CONTACT DETAILS Title Name Surname ID Number Position(Designation) Telephone Facsimile Mobile No Email Address Website Address Physical Address Suburb City/Town Postal Code Province Postal Address Postal Code COEGA Contact Centre, Cnr Alcyon Rd and Zibuko Street, Zone 1, COEGA IDZ 6001 COEGA Contact Centre, Private Bag X6009, Port Elizabeth 6100 Tel: 08610 26342 Email: Page 4 of 5 Rev 7 26/01/2014 SHAREHOLDERS / DIRECTORS / MEMBERS Name Surname ID Number % Equity Woman (y/n) Black (y/n) What is the core business of the company? 1. _____ 2. _____ 3. _____ COEGA Contact Centre, Cnr Alcyon Rd and Zibuko Street, Zone 1, COEGA IDZ 6001 COEGA Contact Centre, Private Bag X6009, Port Elizabeth 6100 Tel: 08610 26342 Email: Page 5 of 5 Rev 7 26/01/2014 FOR OFFICE USE Ref No Date Captured Captured By Signature FOR OFFICE USE - CHECKLIST Company Profile Certified copy of the Company registration documents Certified copies of ID document of the Shareholders / Members Valid BBBEE Certificate Or Letter from Accounting Officer if t/o <R5m Valid Original SARS Tax Clearance Certificate Date Approved Approved By Signature