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Enquiries: E-mail:
Tel No:
SUPPLIER DATABASE REGISTRATION
FOR 2010 TO 2011 FINANCIAL YEAR
NAME OF SERVICE PROVIDER: _________________________________ (To be completed by supplier)
FOR OFFICIAL PURPOSES
Name of Evaluator from SCM: ____________________________________ Persal No: ______________ Signature: ____________________
Date:
Entity Maintenance No: ________________ Captured by: ________________ Persal No: ______________ Signature: ________________ Date: ______________
APPLICATION ACCEPTED
APPLICATION
REJECTED
DoJ & CD Supplier Number
Verified & Captured on Su pplier Database by : ________________ Persal No: ______________ Signature: ____________________ Date:
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SUPPLIER DATABASE REGISTRATION FOR 2010 TO 2011 FINANCIAL YEAR
The Department of Justice and Constitutional Development (DoJ&CD) is an outwardly focused, customer-centered government department mandated to uphold and protect the Constitution and Rule of Law in the interest of a safer and more secure South Africa. DoJ & CD, pursuant to the provisions of the Public Finance Management Act (PFMA), Act 1 of 1999) read with CIPRO Supply Chain Management Policy invites service providers to register on DoJ & CD’s database of suppliers/services as official vendors and suppliers for the 2010 to 2011 Financial Year. Suppliers and service providers currently registered as vendors on the DoJ & CD database should also re-apply for considerations to be re-registered on the DoJ & CD vendor/supplier database. Enterprises owned by HDI”s (Historically disadvantaged Individuals), Women, Youth, People with Disabilities and BEE’S (Black Economic Empowerment) are encouraged to apply. A list of commodities requirements are enlisted in the supplier database application form. Prospective suppliers/service providers may apply to be enlisted on the supplier database for a maximum of five (5) commodities specific as per their principle business, other than those suppliers on SITA transversal contracts. Failure to comply with this condition will invalidate the applications and would not be evaluated further. Supplier Database registration forms are obtainable from: Website: www.justice.gov.za Physical Address: Momentum Centre Postal address: Private Bag X81 329 Pretorius Street Pretoria Pretoria 0001 0001 Enquiries should be forwarded to:
Tel No: E-mail Address Fax No. N.Skosana 012 357 8583 [email protected] 086 640 3113 I. Thusi 012 357 8291 [email protected] 086 688 5470 M. Karabo 012 357 8198 [email protected] 086 642 3759 M.S.Bassier 012 315 4545 [email protected] 086 641 2053
Closing date: 31 October 2010 at 11:00 Completed registration forms may be hand delivered or posted to the above mentioned postal address on or before closing date and time for attention: The Director: Supply Chain Management (DoJ & CD)
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SUPPLIER REGISTRATION FORM
IMPORTANT NOTES Please read carefully before completion of registration form
� To be completed by all vendors seeking registration as an approved supplier; � The supplier registration form must be completed in full and be signed, and forwarded to the National Department of Justice and Constitutional Development at Pretoria with all supporting documentation ; � A company profile which also addresses the evaluation criteria set out in this document must
accompany the registration form but will not be accepted as substitute for the application form – all fields on application form MUST be completed by applicant;
� Successful applicants will be contacted via fax and/or email and must therefore submit an operating fax number and/or email address; failure to comply will result in excluding the supplier from the data base; � Only successful suppliers will be notified in writing on their application been accepted; � Supplier must comply with all the registration-criteria for registration to be finalized - failure to
do so will result in the application being declined. � All shareholders/ Directors/ Members and in case of one-man concern, please furnish identity number plus
copy of identity documents Research & Development contact details:
Telephone: 012 357 8198 / 012 315 1682
Fax number: 086 687 7698
Email: [email protected]
1. SUPPLIER DETAILS(All fields are mandatory)
Details:
Company Name: (Orders will be issued In this name )
Trading Name:
Registration Number:
ID number:
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VAT Number:
Income Tax Number
Telephone Number:
Fax Number:
Website Address:
Postal Address:
Physical Address:
Banking Details
Bank Name:
Branch Name:
Account Type:
Branch Code:
Account Number:
Main Contact:
Name:
Surname:
Position:
Telephone Number:
Facsimile Number:
Cellular Number:
E-mail Address:
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2. SUPPLIER GROUPING DETAILS: (Please mark with an X the relevant box)
Public Company (Ltd)
(Attach a Certified copy of Incorporation (CM3)
Private Company (Pty) Ltd
(Attach a Certified copy of Incorporation (CM3))
Closed Corporation (cc)
(Attach a Certified copy of (CK1 & CK2))
Sole Proprietor
(Attach a Certified copy of ID Document)
Partnership
(Attach a Certified copy of Partnership Agreement)
Trust
(Attach a Certified copy of Trust Document)
Foreign Company
(Attach a Certified copy of Incorporation)
Joint Venture
(Attach a Certified copy of all Members ID Documents
and joint venture agreement signed by all parties)
Consortium
(Attach a Certified copy of all Members ID Documents
and consortium agreement signed by all parties)
Section 21 Company
Government / Parastatals
Other (specify)
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3. PREFERENCE POINTS CLAIMS
List all partners and shareholders (compulsory)
Name Position Citizenship ID Number
% Ownership
Note: where owners are themselves a company or partnership, owners of the holding firm must be identified. HDI Ownership Status: Please read notes below very carefully Instructions and Definitions: (Please read carefully before completing HDI Ownership Status) �Owned: Having all the customary elements of ownership, including the right of decision-making and sharing all the risks and profits commensurate with the degree of ownership interests as demonstrated by an examination rather than the form of ownership arrangements. �Historically Disadvantaged Individuals (HDI): For the purpose of registering as a supplier for the Department, the refutable presumption shall be made that SA citizens who fall into population groups that had no franchise in national elections prior to the introduction of the 1983 and 1993 constitution are Historically Disadvantaged Individuals. It is incumbent on individuals to demonstrate their claims to fall into such population groups on the basis of identification and association with and recognition by the members of such a group. �Women: A female person who is a SA citizen. �Establishment of HDI / Women Equity Ownership in a enterprise: Equity ownership shall be equated to the percentage of an enterprise which is owned by individuals, or in the case of a company, the percentage shares that are owned by individuals who are actively involved in the management and daily business operations of the enterprise and exercise control over the enterprise, commensurate with their degree of ownership. Where individuals are not actively involved in the management and daily business operations and do not exercise control over the enterprise commensurate with their degree of ownership, equity ownership may not be claimed.
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HDI Ownership Status: Historically Disadvantaged Individuals (HDI) % %
Women Equity (WE) %
Disabled Individuals (DI) %
4. SMME status of your enterprise
Please use this table to determine the SMME status of your enterprise Please the relevant box in each column
B. Full time paid employees C. Annual Turnover (millions) D. Total Gross asset value (million)
(property excluded) A. Sector
Medium Small Very Small
Micro Medium Small Very Small
Micro Medium Small Very Small
Micro
Agriculture 100 50 10 5 4 2 0.4 0.15 4 2 0.4 0.1 Mining & Quarrying
200 50 20 5 30 7.5 3 0.15 18 4.5 1.8 0.1
Manufacturing 200 50 20 5 40 10 4 0.15 15 3.75 1.5 0.1 Construction 200 50 20 5 20 5 2 0.15 4 1 0.4 0.1 Retail & Motor 100 50 10 5 30 15 3 0.15 5 2.5 0.5 0.1 Wholesale Trade
100 50 10 5 50 25 5 0.15 8 4 0.5 0.1
Catering, Accommodation
100 50 10 5 10 5 1 0.15 2 1 0.2 0.1
Transport, Storage
100 50 10 5 20 10 2 0.15 5 2.5 0.5 0.1
Finance & Business Services
100 50 10 5 20 10 2 0.15 4 2 0.4 0.1
Repairs/Allied Services
100 50 10 5 30 15 3 0.15 5 2.5 0.5 0.1
Communications
100 50 10 5 20 10 2 0.15 5 2.5 0.5 0.1
Other Trade 100 50 10 5 10 5 1 0.15 2 1 0.2 0.1 Commercial Agent
100 50 10 5 50 25 5 0.15 8 4 0.5 0.1
Community & Social Services
100 50 10 5 10 5 1 0.15 5 2.5 0.5 0.1
Personal Services
100 50 10 5 10 5 1 0.15 5 2.5 0.5 0.1
SMME status of your entity Please the relevant box (According to SMME table) (compulsory) Micro
Very small
Small
Medium
Large
I/We confirm that the information provided in paragraph 3 is correct as at this date
Name in print Signature Designation Date
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5. DECLARATION
Verification of information supplied in this document, including attached documents:
I/We, the undersigned, warrants that he / she is duly authorised to do so on behalf of the supplier, certifies that the information supplied including the annexure, is correct and accurate and acknowledge that: If I found that the information supplied is incorrect the Department of Justice and Constitutional Development will disqualify and remove the supplier from our database permanently. TERMS AND CONDITIONS
- The Department of Justice and Constitutional Development can not guarantee business opportunities. All procurement will be subject to the departmental SCM policy, the general conditions of contract, and applicable legislation.
- All suppliers will be subjected to regular performance service review and could be deregistered if service levels are not maintained.
- The validity period of a quotation must be at least 30 ( thirty) days - Certified documents: Please ensure that The Commissioner of Oath has certified your
company registration documents, and other documents. - Original Tax Clearance Certificate - All shareholders/ Directors/ Members and in case of one-man concern, please furnish identity number
plus copy of identity documents - Verification information supplied will perform against third party source such as SARS,
CIPRO, Safety net, etc. - Please notify the Department immediately of any change to the provided information.
- Pleas ensure all fields are completed. Incomplete application forms will not be processed.
Should you have any queries or if you require assistance completing the form please contact the Research and Development unit of Department of Justice on the following numbers: 012 357 8198 / 012 315 1682.
Supplier Name: ____________________________________________________________
________________________________________ __________________________ Signature of Authorised Representative Signatory Name in Print ________________________________________ __________________________ Signatory Capacity: Signatory ID Number: Signed at __________________________ on this ____ day of________________ 20___
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6. SUPPLIER MAINTENANCE FORM: BAS JYP PERSAL
PLEASE WRITE IN BLOCK LETTERS
I/We hereby request and authorise you to pay any amounts, which may accrue to me/us to the credit of my/our account with the mentioned bank.
I/we understand that the credit transfers hereby authorised will be processed by computer through a system known as "ACB - Electronic Fund Transfer Service", and I/we understand that not additional advice of payment will be provided by my/our bank, but that the details of each payment will be printed on my/our bank statement or any accompanying voucher. (This does not apply where it is not customary for banks to furnish bank statements).
I/we understand that the Department will supply a payment advice in the normal way, and that it will indicate the date on which the funds will be made available on my/our account.
This authority may be cancelled by me/us by giving 30 days notice by prepaid registered post.
Please ensure that the information is validated as per required bank screens
I/We understand that bank details provided should be exactly as per the records held by the bank.
I/We understand that the Department will not assume responsibility for any delayed payments, as a result of incorrect information supplied.
Company / Personal Details
Registered Name
Trading Name
Tax Number
VAT Number
Title:
Initials:
First Name:
Surname:
Regional Office Only
Region:
Reference Number:
Contact person:
Contact Telephone number:
Contact Fax number:
Head Office Only Captured By:
Date Captured:
Authorised By:
Date Authorised:
Supplier code:
SUPPLIER NO
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Address Detail
Postal Address
( Compulsory if Supplier )
Postal Code
New Detail
New Supplier information Update Supplier information
Supplier Type: Individual Department Partnership
Company Trust
CC Other ( Specify )
Department Number
Supplier Account Details (Please note that this account MUST be in the name of the supplier. No 3rd party payments allowed).
Account Name
Account Number
Branch Name
Branch Number
Account Type Cheque Account
Savings Account
Transmission Account
Bond Account
Other (Please Specify)
ID Number IF SPOUSE ACC HOLDER
Passport Number
Company Registration Number / /
*CC Registration
*Please include CC/CK where applicable
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Practise Number
Bank stamp
PLEASE ATTACHED A PRINTOUT It is hereby confirmed that this details have been verified
FROM THE BANK against the following screens:
ABSA-CIF screen
FNB-Hogans system on the CIS4
PLEASE PROVIDE BANK STAMP STD Bank-Look-up-screen
PLUS SIGNITURE OF OFFICIAL Nedbank- Banking Platform under Client Details Tab
Contact Details Business
Area Code Extension
Home
Area Code Extension
Fax
Area Code
Cell Cell Code
Email Address:
Contact Person:
Supplier Signature
Print Name
/ / Date (dd/mm/yyyy)
NB: All relevant fields must be completed
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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.1 Eastern Cape Province
Mark with X Mark with X
Aberdeen Port St Johns (Umzimvubu)
Adelaide Queenstown
Albany Qumbu
Albert Somerset East
Alexandria St Marks
Aliwal North Sterkstroom
Barkly East Steynsburg
Bathurst Steytlerville
Bedford Stutterheim
Bizana Tabankulu
Butterworth Tarka
Cathcart Tsolo
Cradock Tsomo
East London Uitenhage
Elliot Umtata
Elliotdale Umzimkulu
Engcobo Venterstad
Flagstaff Victoria East
Fort Beaufort Willowmore
Glen Grey Willowvale (Gatyana)
Graaff-Reinet Wodehouse
Hankey Xalanga (Cala)
Herschel Zwelitsha
Hewu Jansenville
Hofmeyr Joubertina
Humansdorp Keiskammahoek
Idutywa Kentani
Indwe King William’s Town
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Section 7
LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.1 Eastern Cape Province Location Mark with X Location Mark with X
Kirkwood Mount Ayliff
Komga Mount Fletcher
Lady Grey Mount Frere
Libode Mpofu (Stockenström)
Lusikisiki Mqanduli
Maclear Ngqeleni
Matatiele Nqamakwe
Mdantsane Ntabathemba
Middelburg Pearston
Middledrift Peddie
Molteno Port Elizabeth
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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.2 Free State Province Location Mark with X Location Mark with X
Bethlehem Marquard Bethulie Memel Bloemfontein Odendaalsrus Boshof Parys Bothaville Paul Roux Botshabelo Petrusburg Brandfort Petrus Steyn Bultfontein Philippolis Clocolan Reddersburg Dealesville Reitz Dewetsdorp Rouxville Edenburg Sasolburg Edenville Senekal Excelsior Smithfield Fauresmith Springfontein Ficksburg Steynsrus Fouriesburg Thaba ’Nchu Frankfort Theunissen Harrismith Trompsburg Heilbron Ventersburg Hennenman Viljoenskroon Hertzogville Villiers Hobhouse Virginia Hoopstad Vrede Jacobsdal Vredefort Jagersfontein Warden Kestell Welkom Koffiefontein Wepener Koppies Wesselsbron Kroonstad Winburg Ladybrand Witsieshoek Lindley Zastron
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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED
PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.3 Gauteng Province Location Mark with X
Alberton Benoni Daveyton Boksburg Brakpan Bronkhorstspruit Cullinan Germiston Heidelberg Johannesburg Regional Office Kempton Park Tembisa Krugersdorp Meyerton Nigel Oberholzer Pretoria ( Include Supply to the National Office) Atteridgeville Pretoria North Mamelodi Randburg Randfontein Roodepoort Soshanguve Springs Vanderbijlpark Sebokeng Vereeniging Westonaria
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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED
PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.4 Kwazulu Natal Province (continued on page 17) COURTS IN KZN Mark with X COURTS IN KZN Mark with X Babanango Manguzi Bergville Maphumulo Camperdown Matatiele Chatsworth Melmoth Colenso Mooiriver Dannhauser Mpumalanga Dukuza Msinga Dundee Mtubatuba Durban Mtunzini Emlazi Ndwedwe Ekuvukeni New hanover Empangeni Newcastle Emzumbe Nkandla Enseleni Nongoma Eshowe Nqutu Estcourt Ntuzuma Emnabithi Ongoye Glencoe Paulpietersburg Greytown Phungashe Harding Pietermaritzburg Himeville Pinetown Hlabisa Pongola Hlanganani Port shepstone Howick Richmond Impendle Scottburgh Ingwavuma Simdlagentsha Inkanyezi Stanger Ixopo State attorney Izingolweni Ubombo Kokstad
Umbumbulu
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Section 7
7.4 Kwazulu Natal Province COURTS IN KZN Mark with X COURTS IN KZN Mark with X Kranskop Umzimkhulu Kwamsane Utrecht Ladysmith Verulam Louwsburg Vryheid Madadeni Vulamehlo Magudu Weenen Mahlabatini
LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED
PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LOCATED IN THE SPECIFIC PROVINCEWHERE THE GOODS AND/OR SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.5 Limpopo Province
Location Mark with X Location Mark with X Bochum Phalala Bolobedu Pietersburg Dzanani Potgietersrus Ellisras Praktiseer Giyani Ritavi Hlanganani Sekgosese Letaba Sekhukhuneland Lulekani Seshego Malamulele Soutpansberg Mankweng Thabamoopo Mapulaneng Thabazimbi Messina Thohoyandou Mhala Tshilwavhusiku Mokerong Tshitale Mutale Vuwani Namakgale Warmbaths Naphuno Waterberg Nebo Tshitale Phalaborwa
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Section 7
LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED
PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHINTHE SPECIFIC PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.6 Mpumalanga Province Location Mark with X Location Mark with X
Amsterdam Lydenburg Amersfoort Mbibana Balfour Mdutjana Barberton Middelburg Belfast Mkobola Bethal Morgenzon Breyten Moutse Carolina Nelspruit Delmas Nkomazi Eerstehoek Nsikazi Ekangala Piet Retief Ermelo Sabie Evander Standerton Graskop Volksrust Groblersdal Wakkerstroom Hendrina Waterval Boven Kriel White River KwaMhlanga
Witbank
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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.7 Northern Cape Location Mark with X Location Mark with X Barkly West Keimoes Britstown Kenhardt Calvinia Kimberley Carnarvon Kuruman Colesberg Noupoort De Aar Olifantshoek Douglas (Herbert) Philipstown Fraserburg Pofadder Galeshewe Port Nolloth Garies Postmasburg Griekwastad (Hay) Prieska Groblershoop Richmond Hanover Springbok (Namakwaland) Hartswater Sutherland Hopetown Upington (Gordonia) Jan Kempdorp Victoria West Kakamas Warrenton Kathu
Williston
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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED
PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.8 North West Province Location Mark with X
Bafokeng Bloemhof Brits Christiana Coligny Delareyville Ditsobotla Ganyesa Klerksdorp Koster Kudumane (Tlhaping-Tlharo) Lehurutshe Lichtenburg Madikwe Mankwe Marico Molopo Moretele Odi Potchefstroom Rustenburg Schweizer-Reneke Swartruggens Taung Ventersdorp Vryburg Wolmaransstad
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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED
PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.9 Western Cape Province
Location Mark with X
Location Mark with X
Albertinia Montagu Atlantis Moorreesburg Beaufort West Mossel Bay Bellville Murraysburg Bonnievale Oudtshoorn Bredasdorp Paarl Caledon Piketberg Calitzdorp Porterville Cape Town Prince Albert Ceres Riversdale Clanwilliam Robertson George Simon’s Town Goodwood Somerset West Grabouw Stellenbosch Heidelberg Strand Hermanus Swellendam High Court Cape Town Tulbagh Hopefield Uniondale Khayelitsha Van Rhynsdorp Knysna Vredenburg Kuils River Vredendal Laaiplek Wellington Ladismith Wolseley Laingsburg Worcester Malmesbury Wynberg Mitchells Plain Riversdale
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8. LIST OF COMMODITY SPECIFICS
IMPORTANT NOTICE: PROSPECTIVE SERVICE PROVIDERS MUST MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS. FAILURE TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PROSPECTIVE SERVICE PROVIDERS APPLICATION
No Des cription Mark with an X
No Description Mark
with an X
1 Access Control Systems 29 Computer Consumables
2 Artwork and Painting 30 Computer Hardware, Printer & Components
3 Advertising (in electronic and print media)
31 Computer Networking Contractors
4 Air Conditioning System - Supply and Repairs
32 Computer: Video & Audio Conferencing
5 Anti Virus Software 33 Conferencing Systems 6 Asset Management System Bar-
codes 34 Conference Venues
7 Auctioneers 35 Consulting: Asset Management 8 Audio Visual 36 Consulting: Advertising 9 Awnings 37 Consulting: Auditors
10 Banking Services 38 Consulting: Business Advisor Services
11 Bags, Refuse and Plastic 39 Consulting: Business process analysis and re engineering
12 Binding Services 40 Consulting: Business Strategy 13 Badges Conference, embroidered,
metal 41 Consulting: Contract Law
14 Batteries 42 Consulting: Communication Management
15 Books & Journals 43 Consulting: Communications 16 Blinds 44 Consulting: Competency
Assessment
17 Cashiering Services 45 Consulting: Computer Consulting Services
18 Catering services 46 Consulting: Customer Interface
19 Cellular phone providers 47 Consulting: Customer Satisfaction
20 Change Management 48 Consulting: Emergency & Disaster Management
21 Cleaning Chemicals 49 Consulting: Empowerment Women
22 Cleaning Services 50 Consulting: Employee Health & Wellness
23 Carpets 51 Consulting: Employment Equity and Transformation
24 Clothing General/Protective & Uniforms
52 Consulting: Entrepreneurial Skills
25 Curtaining, Rails and Accessories 53 Consulting: Environmental 26 Clothing General/Protective &
Uniforms 54 Consulting: Executive Coaching
27 Computer Repairs & Maintenance 55 Consulting: Erection Engineers
28 Coffee and vending machines 56 Consulting: Evaluation Assets
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8. LIST OF COMMODITY SPECIFICS
IMPORTANT NOTICE: PROSPECTIVE SERVICE PROVIDERS MUST MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS. FAILURE TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PROSPECTIVE SERVICE PROVIDERS APPLICATION
No Des cription Mark with an X
No Des cription Mark with an X
57 Consulting: Exhibitions 88 Consulting: Litigation
58 Consulting: Exports & Imports 89 Consulting: Library Services 59 Consulting: Financial and accounting
services 90 Consulting: Logistical Services
60 Consulting: Financial and System Integration
91 Consulting: Logistical System
61 Consulting: Financial Administration 92 Consulting Management 62 Consulting: Financial Planning 93 Consulting: Management Tools 63 Consulting: Financial Systems 94 Consulting: Marketing and
Advertising
64 Consulting: Fleet Service Management
95 Consulting: Media Relation
65 Consulting: Forensic Investigation 96 Consulting: Motivational speakers
66 Consulting: Fund Management 97 Consulting: Organizational Design
67 Consulting: Furnaces 98 Consulting: People Transformation
68 Consulting: Geographical Information 99 Consulting: Performance management
69 Consulting: Governance 100 Consulting: Policy Development 70 Consulting: Health Care 101 Consulting: Psychological
Counselling
71 Consulting Human Resources 102 Consulting: Project Management
72 Consulting: Impact Assessment 103 Consulting: Public Relations Management
73 Consulting: Industrial 104 Consulting: Psychological Assessment
74 Consulting: Information technology & Strategy
105 Consulting: Recruitment Services
75 Consulting: Institutional 106 Consulting: Remuneration
76 Consulting: Infrastructure 107 Consulting: Research and Development
77 Consulting: Insurance 108 Consulting: Risk Management
78 Consulting: Interior Decorating 109 Consulting: Skills Development
79 Consulting: Investigation Services 110 Consulting: Survey Research
80 Consulting: Knowledge management 111 Consulting: Talent Management
81 Consulting: Job Evaluation 112 Consulting: Team Building
82 Consulting: Journalism 113 Consulting: Training & Development
83 Consulting: Laboratory 114 Consulting: Tracing Agency & Debt Collection
84 Consulting: Labour Relations 115 Consulting: Website Design 85 Consulting: Landscape Services 116 Corporate Uniform 86 Consulting: Legal Services 117 Courier & Mailing Services 87 Consulting: Legislation Drafting 118 Crockery & Cutlery
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8. LIST OF COMMODITY SPECIFICS MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS
No Des cription Mark with an X
No Des cription Mark with an X
119 Drain cleaning services 156 Gift Promotional 120 Drivers licences permits & Lessons 157 Gardening Services 121 Editing Services 158 Gas and Heating Equipment 122 Electrical Appliances 159 Glassing Contractors 123 Electrical Appliances Household 160 Government Services 124 Electrical Component and Equipment 161 Graphic Design Services 125 Electrical Contractors & Maintenance 162 Government Services 126 Electrical Conveyors 163 Globes, lamps & Fluorescent
tubes
127 Embossing Services 164 Guesthouse & lodges 128 Emergency Medical Suppliers and
Equipment 165 Hardware and Building
Supplies
129 Elevators, Conveyors and Maintenance & repairs
166 Heaters and Heating Equipment
130 Encoding 167 Hiring of Equipment (Sound System & Audio visual)
131 Encrypting software and system 168 Hospitality Service Corporate 132 Engraving Services 169 ID card personalisation
system
133 Engraving Services and Equipment 170 Illustration services 134 Entertainment ( Performers) 171 Imaging Services 135 Entertainment Facilities 172 Illustration services 136 Entertainment Services( Tourists) 173 Industrial chemicals 137 Entertainment Venues and Theatres 174 Information services 138 Envelopes 175 Inspection services 139 Estate Agencies and Consultants 176 Institutes 140 Evacuation Systems 177 Insulation Services 141 Event and Conferencing
Management 178 Intercommunication System
142 Exhibition Centres/Stands 179 Interior Designers 143 Facilitation General Services 180 Interpretation services
magnetic surveys
144 Facilitation Services Conferences 181 Interpreting services languages
145 Fencing Contractors 182 Irrigation contractors 146 Fire Extinguishing 183 Hotel Accommodation 147 Flags and Maps 184 Labels and Labelling services 148 Flooring Contractors 185 Lightning Contractors 149 Florist 186 Locksmiths 150 Footwear 187 Logo: Crockery 151 Framing Services 188 Logo: Design services 152 Franking Machines 189 Logo Engraving 153 Freight Services ( Air, Land and Sea) 190 Licences (Radio & T.V) 154 Furniture removals( Office Furniture) 191 Marketing and
communications Services
155 Gardening Services
192 Market Research
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8. LIST OF COMMODITY SPECIFICS MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS
No Des cription Mark with an X
No Des cription Mark with an X
193 Media Liaison 229 Renovation Services 194 Media/publicity 230 Recording and Transcription
Services
195 Mediator Services 231 Roofing Contractors 196 Mobile homes 232 Safes and Safe removal
Services
197 Network Solutions 233 Sanitary ware 198 Newspapers and Magazines 234 Secretarial Services 199 Number plates 235 Self Defence Training 200 Office Automation Hire 236 Security Equipment - Supply
and Repairs
201 Office furniture 237 Security and Safety services 202 Office Layout Design Services 238 Security Transit 203 Office Buildings Maintenance &
Repairs 239 Seminars
204 Office Machines and Equipment 240 Service Providers Cellular Telephones
205 Organizational Development 241 Signs 206 Packing Material 242 Stationery 207 Paint Supplies 243 Storage facility 208 Partitioning Contractors 244 Storage Systems 209 Paintings 245 Shelves & Shelving 210 Pest Control Services 246 Supply of printed publications 211 Photography Equipment 247 Translation Services 212 Photography Services 248 Transportation service (
including chauffeur services)
213 Plants, Flowers & Decoration 249 Travel agency 214 Printing 250 Telecommunication
Equipment
215 Printing of booklets and publications(design, layout and printing)
251 Telecommunication System
216 Promotional material 252 Tiling Contractors 217 Property Management Services 253 Time and Attendance
Equipment
218 Photography Services 254 Tools and Electrical Mechanical
219 Plumbing Contractors
255 Toilet Paper
220 Professional Bodies & Membership fees
256 Tours and Tourism
221 Publishers 257 Tracking Service Security 222 Quality control services 258 Tracking Service Vehicle 223 Radio Equipment 259 Training Material and
Software
224 Recreation Centers 260 Training Assets Software 225 Recycling Services 261 Training Business Software 226 Refrigeration Equipment and
Repairs 262 Training Business Skills
227 Refuse Conveyers 263 Training Communication 228 Rehabilitation Services Alcohol and
Drug Depend
264 Training: Communication Strategies and Systems
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LIST OF COMMODITY SPECIFICS MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS
No Des cription Mark with an X
No Des cription Mark with an X
265 Training: Community Building 306 Vehicle Audio and Equipment 266 Training: Community Services 307 Vehicle Hiring 267 Training Computer Literacy 308 Vehicle Industry 268 Training: Computer Programming
and Software 309 Vehicle Security and Tracking
System
269 Training: Computer System and Solution
310 Verification Services
270 Training: Conference and Venues 311 Video Recording Services 271 Training: Customer Interactions 312 Venue finders 272 Training: E- Business Strategies 313 Warehouse Services 273 Training: Economic Strategy 314 Waste Disposal 274 Training; Education 315 Waterproofing Contractors 275 Training: Employee Development 316 Window Fitting and Glasses 276 Training: Empowerment Models 317 Web pages and Design 277 Training: Entrepreneurial Skills 318 Web solution Design and
Maintenance
278 Training: Financial Administration 319 Welding Consultants 279 Training: Financial Planning 320 Window Fitting and Glass 280 Training: Financial Systems 321 Wire works General 281 Training: Human Resources 322 Workshop Equipment 282 Training: Information Management 323 Workshop Facilitation 283 Training: IT Services and Strategies 324 Workshop Requisites 284 Training: Labour 325 Writing Articles and Editorials 285 Training: Logistics Systems 326 Writing Services 286 Training: Management 287 Training: Management Tools 288 Training: Multimedia 289 Training: Perfomance Management 290 Training: Personnel Development 291 Training: Project Management 292 Training: Public Relations and
Services
293 Training: Risk Management 294 Training: Secretarial 295 Training: Security Systems 296 Training: Skills Development 297 Training Software Business 298 Training: Stress Management 299 Training: Technical Skills 300 Training: Stress Management 301 Training: Technical Skills 302 Training: Township and Rural
Projects
303 Transcription Services 304 Travel Agency 305 Tyres and Tubes
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PREFERENCE POINTS CLAIM FORM IN TERMS OF THE PREFERENTIAL PROCUREMENT REGULATIONS 2001
PURCHASES
Section 9
This preference form must form part of all bids invited. It contains general information and serves as a claim form for Historically Disadvantaged Individual (HDI) preference points as well as a summary for preference points claimed for attainment of other specified goals NB: BEFORE COMPLETING THIS FORM , BIDDE RS MUST STUDY T HE GENER AL
CONDITIONS, DEFINITIONS AND DIRECTIVES APPLICABLE IN RESPECT OF EQUITY OWNERSHIP BY HIS TORICALLY DISA DVANTAGED IN DIVIDUALS ( HDIs), AS PRESCRIBED IN THE PREFERENTIAL PROCUREMENT REGULATIONS, 2001.
1. GEN ERAL CONDITIONS 1.1 The following preference point systems are applicable to all bids:
- the 80/20 system for requirements with a Rand value of up to R500 000; and
1.2 The value for these quotations is estimated to exceed/not exceed R500 000 and therefore
the 80/20 system shall be applicable. 1.3 Preference points for this bid shall be awarded for:
(a) Price; and (b) Specific contract participation goals, as specified in the attached forms.
1.3.1 The points for this bid are allocated as follows: POINTS
1.3.1.1 PRICE 80 1.3.1.2 SPECIFIC CONTRACT PARTICIPATION GOALS
(a) Histori cally Disadvantaged Individuals: (i) who had no franchise in national elections before the 1983 and 1993 Constitutions 10 (ii) who is a female 7 (iii) who has a disability 3 (b) Other specific goals (goals of the RDP- plus local manufacture) (i) ……. (ii) ……. (iii) ……. (iv) ……. Total points for Price, HDIs and other RDP- goals must not exceed 100 Separate Preference Points Claim Forms will be used for the promotion of the specific goals for which points have been allocated in paragraph 1.3.1.2 (b) above.
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1.4 Failure on the part of a bidder to fill in and/or to sign this form may be interpreted to mean
that preference points are not claimed. 1.5. The purchaser reserves the right to require of a bidder, either before a bid is adjudicated or
at any time subsequently, to substantiate any claim in regard to preferences, in any manner required by the purchaser.
2. GENERAL DEFINITIONS 2.1 “Acceptable quotations ” means any quotation which, in all respects, complies with the
specifications and conditions of bid as set out in the bid document. 2.2 “Quotation” means a written offer in a prescribed or stipulated form in response to an
invitation by an organ of state for the provision of goods, works or services. 2.3 “Comparative price ” means the price after the factors of a non-firm price and all
unconditional discounts that can be utilised have been taken into consideration. 2.4 “Consortium or joint venture” means an association of persons for the purpose of
combining their expertise, property, capital, efforts, skills and knowledge in an activity for the execution of a contract.
2.5 “Contract” means the agreement that results from the acceptance of a bid by an organ of
State. 2.6 “Specific contract participation goals” means the goals as stipulated in the Preferential
Procurement Regulations 2001. 2.6.1 In addition to above-mentioned goals, the Regulations [12.(1)] also make provision for
organs of state to give particular consideration to procuring locally manufactured products. 2.7 “Control” means the possession and exercise of legal authority and power to manage the
assets, goodwill and daily operations of a business and the active and continuous exercise of appropriate managerial authority and power in determining the policies and directing the operations of the business.
2.8 “Disability” means, in respect of a person, a permanent impairment of a physical,
intellectual, or sensory function, which results in restricted, or lack of, ability to perform an activity in the manner, or within the range, considered normal for a human being.
2.9 “Equity Ownership” means the percentage ownership and control, exercised by individuals
within an enterprise. 2.10 “Historically Disadvantaged Individual (HDI)” means a South African citizen
(1) who, due to the apartheid policy that had been in place, had no franchise in national
elections prior to the introduction of the Constitution of the Republic of South Africa, 1983 (Act No 110 of 1983) or the Constitution of the Republic of South Africa, 1993, (Act No 200 of 1993) (“the interim Constitution); and/or
(2) who is a female; and/or
(3) who has a disability:
provided that a person who obtained South African citizenship on or after the coming to effect of the Interim Constitution, is deemed not to be a HDI;
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2.11 “Management” means an activity inclusive of control and performed on a daily basis, by any person who is a principal executive officer of the company, by whatever name that person may be designated, and whether or not that person is a director.
2.12 “Owned” means having all the customary elements of ownership, including the right of
decision-making and sharing all the risks and profits commensurate with the degree of ownership interests as demonstrated by an examination of the substance, rather than the form of ownership arrangements.
2.13 “Person” includes reference to a juristic person. 2.14 “Rand value” means the total estimated value of a contract in Rand denomination that is
calculated at the time of bid invitations and includes all applicable taxes and excise duties. 2.15 “Small, Medium and Micro Enterprises (SMMEs) bears the same meaning assigned to
this expression in the National Small Business Act, 1996 (No 102 of 1996). 2.16 “Sub-contracting” means the primary contractor’s assigning or leasing or making out work
to, or employing another person to support such primary contractor in the execution of part of a project in terms of the contract.
2.17 “Trust” means the arrangement through which the property of one person is made over or
bequeathed to a trustee to administer such property for the benefit of another person. 2.18 “Trustee” means any person, including the founder of a trust, to whom property is
bequeathed in order for such property to be administered for the benefit of another person. 3. ESTABLISHMENT OF HDI EQUITY OWNERSHIP IN AN ENTERPRISE 3.1 Equity ownership shall be equated to the percentage of an enterprise which is owned by
individuals classified as HDIs, or in the case of a company, the percentage shares that are owned by individuals classified as HDIs, who are actively involved in the management and daily business operations of the enterprise and exercise control over the enterprise, commensurate with their degree of ownership.
3.2 Where individuals are not actively involved in the management and daily business
operations and do not exercise control over the enterprise commensurate with their degree of ownership, equity ownership may not be claimed.
4. ADJUDICATION USING A POINT SYSTEM 4.1 The bidder obtaining the highest number of points will be awarded the contract. 4.2 Preference points shall be calculated after prices have been brought to a comparative
basis. 4.3 Points scored will be rounded off to 2 decimal places. 4.4 In the event of equal points scored, the bid will be awarded to the bidder scoring the highest
number of points for specified goals.
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5. POINTS AWARDED FOR PRICE 5.1 THE 80/20 PREFERENCE POINT SYSTEMS A maximum of 80 or 90 points is allocated for price on the following basis: 80/20
minmin180
P
PPtPs
Where Ps = Points scored for price of bid under consideration Pt = Rand value of bid under consideration Pmin = Rand value of lowest acceptable bid 6. Points awarded for historically disadvantaged individuals 6.1 In terms of Regulation 13 (2) preference points for HDI’s are calculated on their percentage
shareholding in a business, provided that they are actively involved in and exercise control over the enterprise. The following formula is prescribed in Regulation 13 (5) (c):
100EP
NOPNEP
Where NEP = Points awarded for equity ownership by an HDI
NOP = The maximum number of points awarded for equity ownership by an HDI in that specific category
EP = The percentage of equity ownership by an HDI within the enterprise or business,
determined in accordance with the definition of HDI’s.
6.2 Equity claims for a trust will only be allowed in respect of those persons who are both trustees and beneficiaries and who are actively involved in the management of the trust.
6.3 Documentation to substantiate the validity of the credentials of the trustees contemplated
above must be submitted. 6.4 Listed companies and tertiary institutions do not qualify for HDI preference points. 6.5 A consortium or joint venture may, based on the percentage of the contract value managed or
executed by their HDI-members, be entitled to preference points in respect of an HDI. 6.6 A person awarded a contract as a result of preference for contracting with, or providing equity
ownership to an HDI, may not subcontract more than 25% of the value of the contract to a person who is not an HDI or does not qualify for the same number or more preference for equity ownership.
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7. BID DECLARATION 7.1 Bidders who claim points in respect of equity ownership must complete the Bid Declaration at
the end of this form. 8. EQUITY OWNERSHIP CLAIMED IN T ERMS OF PARAGRAPH 2.10 ABOVE. POINTS TO
BE CALCULATED FROM INFORMATION FURNISHED IN PARAGRAPH 9.8. Ownership Percentage owned Po ints claimed 8.1 Equity ownership by persons who
had no franchise in the national elections % ………………… 8.2 Equity ownership by women % ……… ………. 8.3 Equity ownership by disabled persons* % …………………
*If points are claimed for disabled persons, indicate nature of impairment (see paragraph 2.8 above) ……………………………………………………………………………………………………………
9 DECLARATION WITH REGARD TO EQUITY 9.1 Name of firm :.............................................................................................
9.2 VAT registration number :.............................................................................................
9.3 Company registration number :…………………………………………………………………
9.4 TYPE OF FIRM
Partnership
One person business/sole trader
Close corporation
Company
(Pty) Limited [TICK APPLICABLE BOX] 9.5 DESCRIBE PRINCIPAL BUSINESS ACTIVITIES …………....................................................................................................................................................
……………….............................................................................................................................................
………………………………………………………………………………………………………… .................
………………………………………………………………………………………………………………………
9.6 COMP ANY CLASSIFICATION
Manufacturer
Supplier
Professional service provider
Other service providers, e.g. transporter, etc. [TICK APPLICABLE BOX]
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9.7 TOTAL NUMBER OF YEARS THE FIRM HAS BEEN IN BUSINESS? ………………..……….. 9.8 List all Shareholders by Name, Position, Identity Number, Citizenship, HDI status and
ownership, as relevant. Information to be used to calculate the points claimed in paragraph 8.
* HDI Status
Name Date/Position occupied in Enterprise
ID Number Date RSA Citizenship obtained
No franchise prior to
elections
Women
Disabled
% of
business / enterprise
owned
*Indicate YES or NO 9.9 Consortium / Joint Venture 9.9.1 In the event that preference points are claimed for HDI members by consortia / joint
ventures, the following information must be furnished in order to be entitled to the points claimed in respect of the HDI member:
Name of HDI member (to be consistent with paragraph 9.8)
Percentage (%) of the contract value managed or executed by the HDI member
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9.10 I/we, the undersigned, who warrants that he/she is duly authorised to do so on behalf of the firm certify that points claimed, based on the equity ownership, indicated in paragraph 8 of the foregoing certificate, qualifies the firm for the preference(s) shown and I / we acknowledge that:
(i) The information furnished is true and correct. (ii) The Equity ownership claimed is in accordance with the General
Conditions as indicated in paragraph 1 of this form. (iii) In the event of a contract being awarded as a result of points claimed as
shown in paragraph 8, the contractor may be required to furnish documentary proof to the satisfaction of the purchaser that the claims are correct.
(iv) If the claims are found to be incorrect, the purchaser may, in addition to
any other remedy it may have - (a) recover costs, losses or damages it has incurred or suffered as a
result of that person’s conduct; (b) cancel the contract and claim any damages which it has suffered
as a result of having to make less favourable arrangements due to such cancellation;
(c) impose a financial penalty more severe than the theoretical
financial preference associated with the claim which was made in the bid; and
WITNESSES: SIGNATURE(S) PROSPECTIVE SUPPLIER
1. ……………………………………… ……………………………………..……
2. ……………………………………… DATE:……………………………….. ADDRESS: ……………………………………….…………………………....
……………………………………….…………………………....
……………………………………….…………………………....
……………………………………….…………………………....
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Section 10
Declaration of Interest 1. Any legal person, including persons employed by the State, or persons who act on behalf
of 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 the sourcing of quotations. In
view of possible allegations of favouritism, should the resulting quotation, or part thereof, be
awarded to persons employed by the State, or to persons who act on behalf of the State, or
to persons connected with or related to them, it is required that the service provider or his
authorized representative shall declare his or her positions vis-à-vis the evaluating authority
and/or take an oath declaring his or her interest, where -
- The service provider is employed by the State or acts on behalf of the State; and/or
- the legal person on whose behalf the supplier database application form or quotation
is signed, has a relationship with persons/a person who are/is involved with the
evaluation of the quotation(s), or where it is known that such a relationship exists
between the person or persons for or on who's behalf the declarant acts and persons
who are involved with the evaluation of the quotation.
2. In order to give effect to the above, the following questionnaire shall be completed and
submitted with the application to register on the CIPRO supplier database.
2.1 Are you or any person connected with the service provider, employed by the State? (Delete
that is not applicable)
*YES / NO 2.1.1 If so, state particulars.
Name & Surname: ………………………………………………………………………………….
Physical & Postal Address: …………………………………………………………………..……
Tel & number: ……………………………..………. Fax number: …………………………...…
Cell number/s: …………………………………… email address: …..……………………..….
2.2 Do you, or any person connected with the service provider, have any relationship (family,
friend, other) with a person employed in the department concerned and who may be involved
with the evaluation or adjudication of this application or quotations? *YES / NO
2.2.1 if so, state particulars.
Name & Surname: ………………………………………………………………………………….
Physical & Postal Address: ………………………………………………………………………..
Tel & number: ……………………………..………. Fax number:…….………………………...
Cell number/s: ………………………………… email address:……..………………………
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2. 3 Are you, or any person connected with the service provider, aware of any relationship
(family, friend, other) between the service provider and any person employed by the department
concerned who may be involved with the evaluation or adjudication of this applicant or quotations?
*YES / NO
2.3.1 If so, state particulars.
Name & Surname: ………………………………………………………………………………….
Physical & Postal Address:…………………………………………………………………..……
Tel & number: ……………………………..………. Fax number: ………………………………
Cell number/s: …………………………………… email address: …………..…………………
2.4 Are any member or shareholder of the entity has been blacklisted with any Government
Department in the last five years and if so provide the details as an accompanying annexure
to this application. *YES / NO
Failing to provide full disclosure in respect to 2.4 will result in the invalidation of the
prospective service provider’s application.
2.4 All members and shareholders of the entity applying for registration must declare all other
business interest in any other entities, as an accompanying annexure to this application.
Failing to provide full disclosure in respect to 2.5 will result in the invalidation of the
prospective service provider’s application.
DECLARATION
I, THE UNDERSIGNED (NAME)
CERTIFY THAT THE INFORMATION FURNISHED THE SUPPLIER DATA BASE APPLICATION FORM
PARAGRAPHS 2.1 TO 2.3.1 OF THE DECLARATION OF INTEREST IS CORRECT. I ACCEPT THAT THE
DEPARTMENT MAY ACT AGAINST ME IN TERMS OF PARAGRAPH 34 OF THE GENERAL CONDITIONS
OF BID, CONTRACT AND ORDER SHOULD THIS DECLARATION PROVE TO BE FALSE.
_______ Signature Date ___________ __________ ____________ Position Name of Service Provider
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Section 11 DoJ & CD ANTI-CORRUPTION TOLL-FREE HOTLINE
0800 701 701
The aim of the Hotline is to enhance an honest work ethic and simultaneously provide
employees and persons not employed by the Department with a mechanism to bring any
unethical business practices to the attention of management.
DECLARATION
I, THE UNDERSIGNED (NAME)
CERTIFY THAT I AM AWARE OF DoJ & CD ANTI-CORRUPTION TOLL-FREE LINE,
WHERE I CAN FREELY REPORT POSSIBLE CORRUPT ACTIONS BY
SUPPLIERS/SERVICE PROVIDERS/CONTRACTORS OR POSSIBLE CORRUPT
ACTIONS WITHIN THE DEPARTMENT AT ANY TIME AND THAT THE DEPARTMENT
WILL TREAT MY IDENTITY AS STRICTLY CONFIDENTIAL.
Signature Date Position Name of Service Provider
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Section 13
13. SPECIAL CONDITIONS:
1. As per section 7 of this supplier registration form entitled “Location where goods and/or services may be required”, prospective service providers must indicate by means of an X where goods and/or service can be provided based on the location of their entity. Only entities registered with the relevant authorities within the specific province and located in the specific province where the goods or services will be considered for registration onto DoJ & CD supplier database. Prospective suppliers must submit a latest original Utility bill (water and electricity) and a certified copy of its entity business registration in respect to the Province applied for. Failing to comply with this condition will invalidate the prospective supplier’s application.
2. A response to each element set out in section 14, Evaluation matrix (as per page 40)
per element must be prepared and submitted with the application to be considered for registered as a supplier on DoJ & CD supplier database.
(a) Demonstrable experience in similar services undertaken as per principle
business (submit a list of four reference with contactable details, description of goods and/or services rendered, at least four (4) letters of recommendation where goods and/or services were rendered, value of contract awarded)
(b) The prospective service providers or in the case of a joint venture, each
party to the joint venture must submit:
(i) original or certified copies of their entities bank statement for a
consecutive period of any three (3) months for the year 2009 and
2010; and
(ii) Certified copies of the latest Audited Annual Financial Statements,
or
(iii) In the case of a newly established entity, submit the latest Audited
Annual Financial Statement or recent financial results and the bank
statement for a consecutive period of any three (3) months for the
latest financial period Failure to compl y with b (i) and (ii) or (iii ) will automatically invalidates the prospective service providers application.
3. Service providers scoring a total point of 60% or more for functionality will be
placed on DoJ & CD supplier database. Service providers who score less than
60% in respect of functionality will be regarded as having submitted a non
responsive application. Therefore service providers are requested to furnish
detailed information in substantiation of compliance to the requirements of the
evaluation criteria (Section 14).
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4. Government Procurement General Conditions of contract (GCC) as issued by
National Treasury will applicable on all instances. The general conditions is
available on the National Treasury website (www.treasury.gov.za)
5. No advance payment would be made for the procurement of goods or services.
Payment would be made in terms of the deliverables or other unless otherwise
agreed upon by other parties (DoJ & CD and the contractor). DoJ & CD will pay
within the prescribed period according to PFMA. 6. Service providers must complete and submit all relevant information/documentation
required below as insufficient information and non compliance to the conditions set
out will invalidate your application
Fax number
E-mail address
Physical address
Postal address
Tel number (s) as contact number
Cell number (s) as contact number
Location where goods and/or services may be required
Commodity listed ( only five (5) commodity specific as per principle Business. Non compliance to this condition will i nvalidate the prospective suppliers application)
Fill all forms completely
Sign all forms
Preference Points Claim Forms
Valid and original SARS Tax Cle arance Certificate (Failing to submit an original valid Tax clearance certificate will invalidate the prospective suppliers application)
Supplier Maintenance Form
Company / CC Registration Certificate (Issued by CIPRO).
A Business profile of entity of not more than five (5) pages.
All shareholders/ Directors/ Members and in case of one-man concern,
please furnish identity number plus copy of identity documents
3 A list of commodities requirements (page 23 to 27) are enlisted in the supplier
database application form. Prospective suppliers/service providers may apply to be
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enlisted on the supplier database for a maximum of five (5) commodities specific
as per their principle business. Where a prospective supplier has indicated more
than five commodities specific such application would not be considered for
evaluation further.
4 Successful supplier providers enlisted of the DoJ CD supplier database must
submit a new valid current Tax Clearance Certificate to the National Office
(Pretoria) before the validity of the current Certificate expires, in order to ensure
that the Department may continuously consider quotations submitted by your
business.
5 It is imperative that only the DoJ & CD supplier database registration form with
supporting documentation and Original Signatures be submitted. Applications with
copied signatures or any part of the supplier application that has been retyped or
redrafted will not be considered and disqualified for reegistration.
6 Suppliers providing information incorrectly or fraudulently in their Supplier
Database Registration form will be restricted from bidding, in addition to any other
action the Department of Justice and Constitutional Development may institute
against such a supplier. Furthermore, in the event of the DoJ & CD being
prejudiced financially, it reserves the right to take legal action against the supplier
Section 14 14. EVALUATI ON CRITERIA
Functionality will be evaluated on a scale of 0 – 4 in accordance with the criteria
below. The rating will be as follows: 0 = Non Response, 1= Poor, 2 = Average,
3 = Good, 4= Excellent
NO CRITERION: 0 1 2 3 4 WEIGHT SCORE 1 Demonstrable experience in
similar services undertaken ( submit a list of four reference with contactable details)
40
2 Financial stability 30