NEW DATABASE FORM - Department of Rural …

1 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 1 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.

2 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 CIBD for construction services, PSIRA for security services and etc. 2 SECTION ONE : CONDITIONS Please note that all information will be treated confidentially. 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.

3 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. 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 HDI equity ownership and the SMME status of the entity.

4 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. 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 3 SECTION TWO.

5 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) Public Company Private Company Close Corporation Section 21 Company Trust Partnership Sole Proprietor Parastatal Non Governmental Organisation Other If selected other, please specify: _____ _____ 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 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.

6 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 5 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.

7 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 6 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 7 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.

8 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 8 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 9 Displays and Stands Published Products Printed Media Electronic Reference Material Signage and Accessories Property.

9 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 10 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 11 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

10 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 12 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)