SUPPLIER REGISTRATION APPLICATION FORM - …

1 Joburg Market Heidelberg Road City Deep Johannesburg 2049 PO Box 86007 City Deep, Johannesburg South Africa 2049 Tel +27(0) 11 992 8000 Fax +27(0) 11 613 7381 E-mail: Non-Executive Directors Mr. Khehla Shubane (Chairperson), Mr. Bongani Nkosi, Mr. Samuel Mafadza, Mr. Terry Tselane, Bishop Nchime Tsekedi, Ms. Shelley Childs, Mr. Caesar Molebatsi, Mr. Sandile Ndlungwane, Mr. Sakhile Masango, Chief Executive Officer (Acting) Mr. Josiah Mazibuko Chief Financial Officer (Acting) Ms. Benvinda Rocha Auditors Auditor General REGISTRATION Number: 2000/023383/07 SUPPLIER REGISTRATION APPLICATION form For Enquiries Contact: SUPPLY CHAIN MANAGEMENT UNIT Tel: 011 992 8000 Email Address: The forms must be submitted at: Joburg Market building, 4 fortune road, Joburg Market Deep Fourth Floor: SCM Office Page 2 of 10 The Joburg Market hereby invites current and prospective suppliers to apply to be accredited and registered on its SUPPLIER Database as required by the Municipal Finance Management Act of 2003 and its Regulations.

2 Henceforth, the Joburg Market will not do business with suppliers that are not accredited and registered on the database. INSTRUCTIONS TO PROSPECTIVE SUPPLIERS: 1. The APPLICATION forms must be completed in full. 2. All the required and supporting documentations must be submitted jointly with the form . Company profiles and brochures are also encouraged. 3. Failure to submit supporting and requested information will lead to your company not being registered. 4. The Checklist for JM Officials section on page 3 is not to be completed by Suppliers. 5. It is compulsory to complete Core Business section. Please be specific in terms of products and/or services that your firm can supply to the JM. Please tick in the appropriate box. This section will enable the JM to afford your company an opportunity to submit quotations (above to R30 and above R30 to R200 (all applicable taxes included)); whenever the opportunities arise.

3 The JM will still invite Request for Quotations (RFQs) through the applicable media. 6. It is compulsory for all suppliers to complete the Broad Based Black Economic Empowerment portion accurately and in full including as B-BBEE levels. Failure to complete this section may lead your company not being registered. Emphasis in this section is on accurate and complete disclosure. Whilst the JM prefers to deal with businesses that embrace and comply with Broad Base Black Economic Empowerment Act, non-complying suppliers will also be registered but not accredited for B-BBBEE purposes. 7. Latest audited financial statements must be supplied with the APPLICATION where applicable. 8. Declaration of Interest section is compulsory and must be completed in full.

4 Failure to complete this section will lead to your company not being registered. 9. Declaration by Business under Oath is compulsory and must be completed in full by all suppliers. Failure to comply with this requirement will lead to you company not being registered. 10. The JM reserves the right to validate all information supplied and any misrepresentation of facts may lead to disqualification and potentially being restricted to do business with other spheres of government and/or other organs of the state. 11. A duly completed form together with supporting documentation must be submitted to the address indicated on the front page. The JM will not accept electronically sent forms or faxes. The JM will update/add new suppliers quarterly.

5 12. Compliance with relevant OHS and Environmental laws to protect, prevent, control or prohibit activities that might impact on the environment and safety of persons, failing to do so may lead to disqualification and suspension of work. CRITICAL Non submission of the following supporting documentation will render your SUPPLIER questionnaire invalid. The SUPPLIER REGISTRATION form must be fully completed and signed Proof of REGISTRATION of the central SUPPLIER database Company REGISTRATION documents Certified share certificates Certified ID copies of shareholders Valid Tax Clearance Certificates Certified copy of a valid B-BBEE certificate or A Sworn Declaration Affidavit Signed Joint venture/ consortium agreement (where applicable) Page 3 of 10 Cancelled cheque or stamped bank confirmation letter not older than a year.

6 CHECK LIST FOR THE NEW DATABASE REGISTRATION FORMS FOR OFFICE USE ONLY SUPPLIER NAME: CONTACT DETAILS: CORE FUNCTION: DOCUMENTS ATTACHED Y N NA Comments MANDANTORY DOCUMENTS 1. Proof of REGISTRATION of the Central SUPPLIER database 2. Valid Tax Clearance or Unique pin issued by SARS 3. Company REGISTRATION Documents 4. Original Cancelled Cheque/Stamped Bank Statement (A LETTER FROM THE BANK WILL NOT BE ACCEPTED) 5. Certified ID Copies Of All Shareholders 6. Completed Declarations Of Interest/MBD4 Forms 7. Completed Declaration Of Business Under Oath OTHER DOCUMENTS REQUIRED 8. Construction Industry Development Board Certificate (CIDB) 9. Public Liability Insurance 10. B-BBEE Scorecard / sworn affidavit B-BBEE exempted micro enterprise 11.

7 Company Profile 12. Proof of REGISTRATION to a Professional Body Regulating your Industry 13. Audited Financial Statement 14. Compensation for Occupational Injuries and Diseases (COID) Certificate 15. Catering Certificate of Acceptability NOTE: Certificate of Acceptability (Caterers): Refer R918 Food Handlers, General Requirements for Food Hygiene and Transportation; Health and Safety plan (Contractors): Refer OHS, , ; Checked For JM Office Use Only Required documents attached Yes No If no state reason Approved (SCM Specialist) Name Signature Date Approved (SNR Fin. Controller) Name Signature Date Approved (Systems Accountant) Name Signature Date Page 4 of 10 SUPPLIER Detailed Information Company: Trading Name: REGISTRATION No: REGISTRATION Date: VAT Reg.

8 No: TAX number: Type of Business Limited (Pty) Ltd CC Partnership Sole Proprietorship Private Individual % Black Ownership % 0-39% 40%-50% 51% and over Indicate actual % % Black Women Owned 0-39% 40%-50% 51% and over Indicate actual % % Black People with Disabilities 0-39% 40%-50%W 51% and over W 40%-50% 51% and over Indicate actual % % Black Youth 0-39% 40%-50%W 51% and over W 40%-50% 51% and over Indicate actual % Company Size Generic Qualifying Small Enterprise Exempted Micro Enterprise Recognition levels as per B-BBEE 1 2 3 4 5 6 7 8 Company Annual Turnover in South African Rands, for the last financial year R Line of Business: Physical Address of Trading Business Building: Street: Town: City: Post code Postal Address: Building: Street/PO Box: Town: City: Postcode: Contact Details: (include the area code) Fax: Telephone: Page 5 of 10 Cellular: E-mail Banking Details Bank Name: Branch Name: Account Holder Name: Brach Code Account No.

9 Authorisation for electronic transfer of funds (EFT) to SUPPLIER s bank account I, the undersigned hereby authorise the Joburg Market to credit my/the company account via Electronic Funds Transfer as afore mentioned with the amount payable/due to specified beneficiary for goods and services rendered. Please note: If a cancelled cheque or stamped bank statement is not attached to Bank to confirm the information given above. BANK STAMP _____ _____ Full Name Capacity _____ _____ Date Signature Directors/Owners: (Please indicate name and residential address of all directors/owners) Surname: First Name: Identity Number Address Town: City: Home Tel No: Surname: First Name: Identity No: Page 6 of 10 Address: Town: City: Post code I_____ hereby certify that the information contained in this APPLICATION is true and correct and fully understood by me.

10 Thus done and signed at _____ on this, the _____day of _____20__ _____ Signature Page 7 of 10 Please tick whichever is applicable For queries, please e-mail to or at telephone: (+27) 11 992 8000 Core Business Please indicate by ticking appropriate box below, in which sector of the economy your business is predominantly carried out. If other, please specify Sub-categories Tick Stationery supplies and printing Clothing and textiles Recruitment and placement services Training and Development Specialists Computer equipment and consumables supply Management Consultants Firefighting equipment Furniture Laboratory equipment and services Medical Supplies Chemicals Brokers Hire and leasing services Finance and Business services Cash collection agents Advertising, Media and Communication Hotel accommodation Exhibitions, road shows.