SUPPLIERS’ DATABASE REGISTRATION FORM

1 TABLE 1: ORGANISATIONAL DETAILS Company Name of Business as registered with the Registrar of Companies Trading As Holding Company Company REGISTRATION number Postal Address Physical Address Contact Person: Telephone No: Cellular No: Fax Number e- mail address VAT REGISTRATION number Average annual turnover Which sector does your company belong to? (Refer to Table:9) Core Business (Refer to Table: 12) TABLE 2: BANKING DETAILS (Attach bank stamped proof/copy of cancelled cheque) Name of Bank: Branch Name: Account Number: Type of Bank Account: TABLE 3.

2 BBBEE RATING DETAILS (Attach a certified BBBEE Certificate or a letter from the accountant/auditors) Water for Growth and Sustainable Development Corporate Services Division Supplier DATABASE REGISTRATION form Page 1 of 9 Has your company been rated as per BBBEE by an accredited agency? If YES, attach a BBBEE Certificate. Is your company an Exempted Micro Enterprise (EME)? - Annual turnover of million or less). Submit a letter from the registered accountants/bookkeeper/BBBEE CERTIFICATE Is your company a Qualified Small Enterprise (QSE)?- Annual turnover between and million Is your company a Large Enterprise?

3 - Annual turnover > R35million TABLE 4: TYPE OF BUSINESS (PLEASE TICK ONE (1)) TYPE OF BUSINESS MARK WITH X DOCUMENTS REQUIRED A. Sole Proprietor (One-Person Business) ID Copy B. Public Company LTD Copy of certificate of Incorporation (CM 1) C. Private Company (PTY) Ltd ID Copies & Company REGISTRATION Certificate (CM 1) D. Close Co-operation ID Copies & Company REGISTRATION Certificate (CK 1 and CK 2) E. Incorporated Copy of certificate of Incorporation (CM 1 and CM 19) F. Partnership Partnership Agreement, ID Copies and Tax Certificates of members G.

4 Co-operatives Co-operative REGISTRATION Certificate, ID Copies & Constitution H. Joint Venture JV Agreement, Member s ID Copies & Tax Certificates I. Trust Copy of Trust Document J. Section 21 Company NGO s REGISTRATION certificates with CIPRO, a valid constitution K. Parastatal/Government REGISTRATION certificates if registered TABLE 5: OWNERSHIP STRUCTURE (Please tick the relevant percentage) Business Tick (X) Traditional white company Black Company ( 100 % black owned) Black Company ( - 75% black owned) Black empowered company ( - 50% black owned) Black influenced companies (5% - 25%) Engendered company (>30% owned and managed by black women) SUBMIT THE form WITH ABOVE DOCUMENTS TO: Supplier Management Specialist Umgeni Water.

5 Supply Chain Management P O Box 9, Pietermaritzburg, 3200 or 310 Burger Street, Pietermaritzburg, 3201 Enquiries: 033 341 1008 or 033 341 1045 TABLE 6: OWNERSHIP GROUPS BEE EQUITY OWNERSHIP PERCENTAGE OF TOTAL SHARES OWNED BY EACH OF THE FOLLOWING GROUPS Group (this must add-up to 100% of ownership Percentage Group Percentage Group Percentage African Ownership of the whole company % African Female % African Disabled % Coloured Ownership of the whole company % Coloured Female % Coloured Disabled % Indian Ownership of the whole company % Indian Female % Indian Disabled % White Ownership of the whole company %)

6 White Female % White Disabled % Foreign Ownership of the whole company % Foreign Female % Foreign Disabled % TABLE 7: OWNERSHIP INFORMATION List ALL persons/entities who are owners in the business. (Compulsory) Full name Designation Exec/ Non Exec Race ID Number TABLE 8: BOARD MEMBERS Please indicate percentage BEE control at board level if any. Additional Documentation to be attached: Full name Designation Exec/ Non Exec Race ID Number TABLE 9.

7 SECTORS (Indicate applicable sector related to the goods and services that you supply) SECTOR TICK only 1 (X) SECTOR TICK (X) only 1 (X) ADMINISTRATION HEALTHCARE PROPERTY MAINTENANCE HOSPITALITY CHEMICAL INDUSTRY INFORMATION & COMMUNICATION CONSTRUCTION PETROLEUM & LIQUID FUELS ELECTRICAL PROFESSIONAL SERVICES-ENGINEER GENERAL CONSUMABLES PROFESSIONAL SERVICES-LEGAL GENERAL EQUIPMENT PROFESSIONAL SERVICES-ACCOUNTI ENVIRONMENTAL SERVICES PROFESSIONAL SERVICES-OTHER EQUIPMENT PIPES FINANCIAL SERVICES & INSURANCE RETAIL FORESTRY SAFETY & SECURITY HEALTHCARE TRAINING HOSPITALITY TRANSPORT.

8 FREIGHT & LOGISTICS FORESTRY SUPPLIER S DECLARATION OF INTEREST (COMPULSORY) 1. Any legal person, including persons employed by the state , or persons having a kinship with persons employed by the state, including a blood relationship, may make an offer or offers in terms of this invitation to tender (includes a price quotation, advertised competitive tender, limited tender or proposal). In view of possible allegations of favouritism, should the resulting tender, or part thereof, be awarded to persons employed by the state, or to persons connected with or related to them, it is required that the supplier or his/her authorised representative declare his/her position in relation to the evaluating/adjudicating authority where- - the supplier is employed by the state.

9 And/or - the legal person on whose behalf the tender document is signed, has a relationship with persons/a person who are/is involved in the evaluation and or adjudication of the tender(s), or where it is known that such a relationship exists between the person or persons for or on whose behalf the declarant acts and persons who are involved with the evaluation and or adjudication of the tender. 2. In order to give effect to the above, the following questionnaire must be completed and submitted with the tender. Full Name of supplier or his or her representative:_____ Identity Number:_____ Position occupied in the Company (director, trustee, shareholder ):_____ Company REGISTRATION Number:_____ Reference Number:_____ VAT REGISTRATION Number:_____ The names of all directors / trustees / shareholders / members, their individual identity numbers, tax reference numbers and, if applicable, employee / persal numbers must be indicated in paragraph 3 below.

10 State means (a) any national or provincial department, national or provincial public entity or constitutional institution within the meaning of the Public Finance Management Act, 1999 (Act No. 1 of 1999); (b) any municipality or municipal entity; (c) provincial legislature; (d) national Assembly or the national Council of provinces; or (e) Parliament. Shareholder means a person who owns shares in the company and is actively involved in the management of the enterprise or business and exercises control over the enterprise. Are you or any person connected with the employee YES / NO presently employed by Umgeni Water ?