SUPPLIER APPLICATION FORM 2017/2018

1 1 SUPPLIER APPLICATION form 2017 / 2018 Return to: namibia Qualifications Authority Corner of Bismarck & Dr. W Kultz Street Windhoek 2 To be completed by all vendors seeking registration as an approved SUPPLIER /service provider of goods, works and services to namibia Qualifications Authority The APPLICATION form must be completed in full and be signed. All Fields on the APPLICATION must be completed by the applicant. A company profile should accompany the registration form , but will not substitute accepted as a substitute for the APPLICATION form - all fields on APPLICATION must be completed by the applicant Applicants may be contacted via email and must therefore submit operating email addresses.

2 It should be noted that the namibia Qualifications Authority reserves the right to accept or reject any APPLICATION on reasonable ground. NOTE WELL: The following should accompany the APPLICATION 1. Certified copy of company registration document 2. Tax Good Standing certificate 3. Company Profile 4. A valid Affirmative Action Compliance Certificate , proof from Employment Equity Commissioner that a bidder is not a relevant employer, or exemption issued in terms of section 42 of the Affirmative Action Act, 2008. 5. A certificate indicating SME status(for Bids reserved for SMEs) Applicant must comply with all the registration criteria for registration to be finalized, failure to do so may result in the APPLICATION being declined 1.

3 SUPPLIER Details Company Registration number Income Tax number Email address Telephone Number Fax Number Number of fulltime employees 2. Postal Address Physical Address 3 3. Company/ SUPPLIER classification (mark with x) Services Goods Region Town 4. Please tick the relevant box and supply copy Tax Good standing certificate Attached Expiry date VAT Registration No: 5. Type of Firm Please tick the relevant Box and supply a certified copy of registration document 1 Private Company (PTY) LTD 2 Close Corporation (CC) 3 Public Company LTD 4 Partnership 5 Other (specify) 6.

4 Main Contact for the company Name Resignation Telephone Number Cellphone Number Fax Number Email Address 4 7. Enterprise Status (mark with x) SME Large 8. List all directors/members/partners/shareholders Name Position Held ID Number/Passport/Registration number 9. Trade Experience Name Three trade references Business Name Contact number Contact person Value of business in N$ 10. Financial Information Indicate Annual turnover excluding VAT during the past three years Year Annual Turnover N$ 5 11. Declaration of any conflict of interest I/We the undersigned acknowledge(s) that : The information furnished is true and correct Any conflict of interest will be declared in the comment space below Have you been providing services /products to namibia Qualifications Authority for the past 12 months?

5 If yes, furnish particulars _____ _____ 12. Are you or any person connected with the bidder applicant presently employed by the NQA? Yes NO NO Yes 6 13. Do you presently, or will you potentially have any conflict of interest in connection with a supply contract with the NQA? (A conflict of interest may arise in particular as a result of economic interests, affinities of various forms, family or emotional ties, or any other relevant connection or shared interest) _____ _____ _____ _____ Full Name Capacity _____ _____ SIGNATURE DATE 7 LIST OF GOODS AND SERVICES Suppliers may choose maximum 4 commodities (mark with x ) 1.

6 Goods Supply of: Furniture & Fittings Computer Equipment (Desktops, Monitors, Laptops etc) Office equipment (Photocopy, Projectors, Cameras, Audio & Video systems, Microwaves, Electrical Kettle, Fridge etc.) Air conditioners Motor vehicles Including Trailers Corporate Clothing (Uniform) Flowers Awards / Framing of certificates Promotional Items Corporate Gifts Blinds & Awnings Carpets Crockery, Cutlery, glasses, Table Cloths & other related utensils Groceries / refreshments Cleaning Materials Protective clothing Shelving (Steel and Wood) First Aid Kit & Equipment Newspapers, Periodicals, Journal, Publications and other Media Sportswear and related Sport Supplies Locks & Keys Intercom systems Safes Remote Control, Roller Shutter doors, Turnstiles and booms Cartridges Telephonic equipment including headsets etc.

7 2. Works Repair & Maintenance of Office Equipment Construction & renovation Plumbing Civil work Civil Engineering 8 Air-conditioning specialist Electrical Maintenance Fire Extinguisher Services Painting 3. Consultancy Services Management Consultancy Performance management Consultancy Personal Development Consultant Remuneration and salary structuring Consultancy Skills Analysis and Development Consultancy Staff wellness services ( HIV/AIDS, Cancer & Team building) Transcription Services Voluntary Counseling testing Training & Development Consultants Recruitment Agencies Industrial Relation Services IT Professional Services Architectural Services Quantity surveyor services Interior design Services Audit services (External) Quality Assurance Consultancy (SMEs) Procurement advisory Services Legal (Advisory )

8 Services Surveillance Services 4. Non- Consultancy services Accommodation in Various Towns in namibia Accommodations International Air ticket and transportation services Advertising services Branding & Marketing services Layout & designing Electronic Media 9 Outdoor/ Billboard media Printed Media (Flyers, Brochures) Printing Services Licensing & Computer software Dry Cleaning Services Courier Services Cleaning Services Security Services Insurance Services Telephone services Internet Connection services Catering Services Conference Facilities / Venues Carpet/ Upholstery Cleaning Air-conditioning services Archiving & Related Services IT Hardware, Network, Maintenance and Support Removal Services (Furniture etc) Renovations (Dry walls/partitioning, ceiling, flooring, Painting) CCTV system services (Network cameras, DVR, Backup)

9 Fraud detection Services Investigations Short training Courses & Workshops ICT Training Procurement Training Quality Assurance Training Human Resources Training Corporate Training Car Hiring Services Stitching and Binding Services