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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
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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).
Bank statement.
Operating contact and fax numbers.
Company profile with company letterhead must be attached.
Certified copies of ID (shareholders/ members).
CK1.
Proof of registration for any services/ consultancy that requires registration with professional bodies.e.g. CIBD for construction services, PSIRA for security services and etc.
Valid and original tax clearance certificate.
Declaration of Interest ( SBD4)
Declaration of bidder’s past supply chain management practices ( SBD8)
BBBEE Status Level of Contribution Certficate
NB: It is recommended that Departments add the following declaration to their Supplier Registration Forms for the Supplier to sign:
For purposes of section 256 of the Tax Administration Act of 2011 (the TAAct), the contractor / service provider authorises the South African Revenue Service to disclose ‘taxpayer information’ as contemplated under the provisions of Chapter 6 of the TAAct in relation to the compliance status of tax registration, tax debt and filing requirements of.
________________. _______________ _____________
Name of other party here Signature Date
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SECTION ONE : CONDITIONS
1.1 Please note that all information will be treated confidentially.
1.2 Applications that are incomplete or which are not accompanied by the required documents will be disqualified.
1.3 Completed application forms should be posted to or hand delivered at the above mentioned addresses
1.4 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. 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.
1.5 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.
1.6 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 BBBEE status of the entity. Should a contract be awarded to an entity as a result of incorrect particulars on the status of an 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 Regulation, cancel the contract and to claim for damages.
1.7 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
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SECTION TWO : SUPPLIER INFORMATION
2.1 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
2.2 Company Addresses
Postal Address Town Region Code
Physical Address Town Region Code
2.3 Company Type
(Mark with an X in the applicable column)
Public Company Private Company Close Corporation Section 21 Company Trust Partnership Sole Proprietor Parastetal Non-Governmental Organisation Other
If selected other, please specify: ________________________________________________________
__________________________________________________________________________________
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2.4 Contact Person Details
Contact Person Full Name Position in Company Identity Number Telephone Number Fax Number E-Mail Address Telephone Number Cell Phone Number
2.5 Contact Person Addresses
Postal Address Town Region Code
Physical Address Town Region Code
2.6 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. 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 e.g. Region Town A, Town B Eastern Cape Free State Gauteng Limpopo Kwa-Zulu Natal Mpumalanga Northern Cape Western Cape Northwest
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2.7 Ownership of Company
Full Name Position in Company Identity Number Telephone Number Fax Number E-Mail Address Telephone Number Cell Phone Number Percentage Owned
Please indicate ownership on other Companies with percentage owned.
Name of Company Company Registration Nr Percentage Ownership
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2.8 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. The main commodity is bolded for your ease of reference and sub-commodities are listed below, therefore you may select all sub-commodities under one commodity.)
PLEASE NOTE THAT SERVICE PROVIDERS ARE LIMITED TO THREE (3) COMMODITIES ONLY
ANNEXURE A
List of Goods Commodities (The main commodity is bolded for your ease of reference)
Tick
Agricultural Equipment and Accessories
Agricultural Equipment
Agricultural Accessories
Irrigation system and Equipment
Farm Implements
Agricultural Supplies
Live Animals
Animal Feed
Seeds, Bulbs, Seedlings and Cuttings
Fertilizers, Plant Nutrients and Herbicides
Pest Control Products
Farm tools, spades, rakes
Air Conditioning, Circulating and Heating Equipment
Air Conditioner
Air Conditioner Regulator
Air Circulating Ventilator
Fans
Heaters
Air treatment : purifier, humifier, dehumidifier
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Cold & Freezer room Installation, Maintenance and repair
Accommodation Furniture and Furnishings
Reception Chairs and Couches
Benches
Carpet
Blinds and Curtains
Accommodation Furnishings
Outdoor Furniture and Furnishings
Tables
Communication Equipment and Accessories
Communication Devices and Accessories
Communication Equipment
Mics
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
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Carry Bags
Cases
Luggage and Travelling Bags
Equipment Cases
Cleaning Equipment and Supplies
Cleaning Equipment
Cleaning Supplies
Hygiene Supplies
Protective Gear
Fire Equipment
Fire Beater
Fire Trailer Water Pump
Vent Fire Knap Sack Spray
Wooden Handle Fire Beater
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, Scarf and Belts
Footwear
Protective Apparel
Groceries
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Beverages
Bread and Bakery products
Groceries and Vegetables
Dairy Products
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
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
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Boardroom Tables
Office Furnishings
Tables and Counter Tops
TV Screen
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
Promotional Items and Gifts
Corporate Gifts
Promotional Items
Displays and Stands
Published Products
Printed Media
Electronic Reference Material
Signage and Accessories
Engravers
Property, Land and Temporary Shelter
Prefab House
Mobile House
Shelter
Land
Fixed Property
Poultry House
Recreational and Sporting Equipment and Accessories
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Sports Equipment and Accessories
Sports Kit
Jumping castle
Swimming pool
Safety and Security Equipment and Accessories
Safety Equipment
Security Accessories
Alarm and Security Systems
Locks and Handles
Fire Extinguisher
Security Gates and Bugler doors
Biometric reader
Smoke Sensor
X-ray Equipment
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
File Dividers and Indexes
Glue, Labels and Tapes
Markers and Highlighters
Paper and Board
Pens and Refills
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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
Grinding, Cutting and Sharpening Equipment
Scaffolding and Ladders
Sliding Gates
Swing Gates
Barricades
Gate Automation
Artwork Equipment
Audio Visual Equipment (Screen and Sounds)
Maintenance Supplies and Accessories
Electrical Supplies
Plumbing Supplies
General Maintenance Supplies and Accessories
Surveying and Measuring Tools
Surveying Tools
Measuring Tools
Cartographic
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Petroleum
Diesel
Transmission oil, Hydraulic oil, Brake fluid
LIST OF SERVICES COMMODITIES
Auctioneer Services
Live Stock Auction
Vehicle Auction
Property Auction
Furniture Auction
House Auction
Agricultural Support
Participatory Situation Analysis
Land Resource Assessment / Feasibility Study
Research
Farm Management Development and Support
Farm Management Planning
Agricultural Economic 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
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Carpet Cleaning Services
Garden and Plant Maintenance Services
Vehicle Cleaning Services
Waste Management Services
Community Support / Project Support
Legal Entity Establishment
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, Road Markings, Bridges
Mechanical - Engineers
Fencing – Including Material and Installation, Steel Security Fencing Concrete- SQ
Structural Renovation
Paving and Drive Ways
Fabricators, structural Steelwork Fabrication and Erection SL
Roofing
Tilling
Car Ports
Asphalt Works Supply and Lay-SB
Disaster Management Training
Training in Fire Prevention
Training in Thunderstorm
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Training in Drought
Training in Floods
Training in Fire Protection
Training in Handling Dangerous Goods
Training in Environmental Management
Equipment Hire
Catering Equipment
Construction Equipment
Earthmoving Equipment
General Equipment
Tents and Marques
Musical Equipment
Plants
Education and Training Services (Certification Required)
Professional Training
Alternative Educational Systems
Educational Institutions
Specialized Educational Services
Training Courses (Agri Sector e.g. Soil Rehabilitation)
Training (Construction Sector)
Training (Gender)
Training (Sign Language Interpreters)
Training in Soil Rehabilitation
General Building Maintenance and Repair Services (Certification Required)
Locksmith Services
Partitioning Services
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Window Services
Fumigation Services
Electrical Services
Plumbing Services
Welding Services
Health Services
Wellness Services
Occupational Health & Safety
Ambulance Services
First Aid Training
Interior Decorating and Household Services
Dry Cleaning and Laundry Services
Upholstery Services
Floor Ware Installation Services
Interior Decorating Services
Installation Services of Curtains and Blinds
Wall Ware Services
Plants Hire and Maintenance
Information Technology Services
Installation Services
Specialized IT Services
Hardware Repairs and Maintenance Services
Data Management and Backup Services
Upgrades and Maintenance
G.I.S – System Design
Database Development and Design
Adaptive technology for Blinds and Visually Impaired
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Land Tenure Specialists
Rights Enquiries
Act Commissioners
Lease of Equipment and Machine
Beverage Vending Machine
Photocopy Machine
Water Coolers
Logistical Services
Catering Services
Exhibition Centre and Meeting Facilities
Event Management Services
Bed and Breakfast
Flight Reservations
Accommodation
Seminars/ Workshops/ Conferences
Management and Business Professionals and Administrative Services (Certification Required)
Management Advisory Services
Subscriptions Services
Real Estate Services
Marketing and Distribution Services
Policy Development and Management Services
Document and Information Management Services
Business Administration Services
Policy Expert : Green and White Paper
Monitoring and Evaluation
Land Reform Programme Management M&E
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Project Monitoring and Evaluation
Organisational Monitoring and Evaluation
Diagnostic Evaluation Studies
Indicator Protocols
Monitors and Evaluation Software
Human Resources Services
Affirmative Management
Change Management
Discipline, Grievances and Dispute Resolutions
Personnel Placement (Recruitment) Agencies
Work Study
Competency Skills
Facilitation
Gender Equity Specialist Services
Data Captures
Administrators
Network Controllers
Centennial Systems Integrator’s
Training of Trainers
Rural Development Coordinator
Conflict Management
Response Handling
Credentials Verification
Performance Management
Skills Audit
Competency Test
Psychometric Test
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Training in GIS
Human Resources Development Services
Human Resources Management Services
Legal Services (Certification Required)
Conveyance
Notaries / Notary Public
Land Legal Specialist
Land Reform Law Specialist
Land Reform Mediator
Legal Advisor
Drafters
Legal Entities Specialist
Discipline, Grievance and Dispute Resolutions
Labour Law Specialist
Commercial Law
Arbitrators
Business Plan
Business Plan
Auditing Services (Certification Required)
Financial and operational Audit
Forensic and Investigation Audit
Information Technology Forensic Audit
Information technology Audit
Legal Compliance Audit
Performance Management Audit
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Financial Services (Certification Required)
Business and Financial Advisory Services
Finance Systems Designing Services
Charted Accounts Services
Land Management Support
Farm / Property Management On-Site
Lease Management
State Land Issues
Audit on State Land
Land Use Investigation
Land Reform Services
Land Development Planning Services
Land Reform, Restitution, Redistribution and Land Tenure Programme Services
Agricultural Support and Technical Project Support Services
Institutional and Social Development Services - LR Programme
Land Surveying (Certification Required)
Land Surveyors
Publications, Communication and Information Services
Advertising on newspapers
Publications
Books
Marketing
Video Coverage
Multi-Media
Writing and Translations Services
Printing and Reproduction Services
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Photographic Services
Graphic Design Services
Solar Installation and Services
Solar Installation and Repairs
Town and Regional Integrated Rural Development Planning
Regional and Integrated Rural Development Planning
Township Establishment
Engineering Support
Environmental Impact Assessment / Environmental Scoping
Land Use Planning
Spatial Planning
Consolidation, Sub-divisions and Registration of Servitudes
Relocation, Removals and Storage, Transportation and Mail Services
Courier Services (Mail and Cargo Transport)
Driving School
Bus and Public Transport
Office Furniture and Household Relocation, Removal and Storage
Distribution and Delivery Services
Chauffer and Shuttle Services
Transportation or Moving of Livestock Services
Security and Safety Services (Certification Required)
Security and Personal Safety
Security Surveying Services
Hardware and Software : Installation, Replacement and Labour
CCTV Camera
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Telecommunication Services
Telecommunication Installation
Telecommunication Maintenance and Repairs
Services and Repairs
Service and Repairs of Office Machine
Service and Repairs of Furniture
Service and Repairs of Equipment
Duct Installation
Repair od Sound
Engine services (Car service)
Repair and Installation of Glasses
Water Provision (Certification Required)
Water Provision Contractors / Consultants
Borehole Construction
Water Tanks
Pump Stations
Reservoir
Water Reticulation
Sewerage Systems
NB: Entities are free to supply details of any other products or services they render which are not included on the above lists.
………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..
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2.9 References
Please list contracts/assignments completed by your company in the last three (3) years in relation to the commodities you linked your company to.
Work Performed Client Contact Person and Telephone Number
SECTION THREE : BBBEE DECLARATION
3.1 Equity Ownership
Please indicate in %, shares owned by the following groups: (Compulsory)
Group Male Female Disabled African Coloured Indian White
3.2 BEE
Please indicate the Management structure in % of the total percentage owned.
Group Percentage Owned African Coloured Indian White
3.3 BBBEE
Has your company been assessed for BBBEE? (Yes/No) Which assessment company has provided your company with your BBBEE rating?
What is your BBBEE rating? Please attach copy of Certificate (Is Certificate attached?)
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3.4 SMME Status
(Mark with an X in the applicable column)
Micro Small Medium Large
4. DECLARATION
I/We the undersigned declare that:
Declare that the information supplied/ provided (including any attachments) is complete and correct to the best of my/our knowledge. I/We understand that any false information n supplied could lead to my/our application being disqualified.
-------------------------------------------------- ----------------------------------------
Signature of Owner or Authorized Date
Representative
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SECTION FOUR : OFFICE LIST FOR DATABASE DEVELOPMENT
OFFICE PHYSICAL ADDRESS CONTACT NUMBERS 1 PSSC: KwaZulu Natal 270 Jabu Ndlovu Street,
Pietermaritzberg 033 264 9500/6546
2 PSSC: Eastern Cape Block H, Ocean Terrace Quigney, East London
043 743 0078
3 PSSC: Western Cape Van der sterr Bulding, Rhodes Avenue, Mowbray
021 658 4300/4482
4 PSSC: Free State SA Eagle Building,136 Maitland Street, Bloemfontein
051 447 8465/ 6140
5 PSSC: Northern Cape Corner Knight and Stead Street 6th Floor New Public Building, Kimberley
053 830 4000/4041
6 Mpumalanga Provincial Land Reform Office
Home Affairs Building 4th Floor Cnr Henshall & Andrew Street, Nelspruit
013 755 3499
7 Mpumalanga Regional Land Claims Commission
30 Samora Machel Drive, Restitution House, Nelpruit 1200
013 756 6093/6088
8 Limpopo Provincial Land Reform Office
Andria Building, Second floor, Cnr Schoeman and Rissik Street, Polokwane
015 297 3539
11 Limpopo Regional Land Claims Commission
Kagiso House, Cnr Schoeman & Rissik Street, Polokwane
015 284 6300
12 PSSC: North West Shama Investment Building 9 Shippard, Mafikeng
018 397 9700
13 North West Regional Land Claims Com-mission
ABSA Building, Ground Floor, Cnr Provident & University Drive, Mmabatho
018 389 9600/9620
14 PSSC: Gauteng 1145 Burnett Street, Hatfield, Pretoria 0025
012 432 4200
15 Gauteng Regional Land Claims Commis-sion
9 Bailey Lane, Arcadia, Pretoria 012 310 6500/6526
16 Head Office 184 Jacob Mare Street, Old Building, Room 14D, Pretoria
012 312 9864/9463/9847
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PW1423
Captured By:
Date Captured:
Authorised By:
Date Authorised:
Supplier code:
Enquiries. :
BAS PMIS LOGIS WCS Tel. No.:
OFFICE: ……………………………
The Director General : National TreasuryDEPT OF RURAL DEVELOPMENT AND LAND REFORMI/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 thirty days notice by prepaid registered post. Please ensure information is validate 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 responsibiliy for any delayed payments, as a result of
incorrect information supplied.
Trading Name
Tax Number
VAT Number
First Name:
Surname:
Street Address
Postal Code
New Supplier information Update Supplier information
Supplier Type: Individual Department Partnership
Company Trust
CC Other ( Specify )
Department Number
Postal Address
New Detail
DEPARTMENT OF RURAL
DEVELOPMENT AND LAND
REFORM
Head Office Only
Company / Personal Details
SUPPLIER MAINTENANCE:
CONTRACTOR
CONSULTANT
Registered Name
Title:
Initials:
Postal and Street Address Detail of the Company / Individual
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PW1423
This field is compulsory and should be completed by a bank official from the relevant bank
Account Number
Branch Name
Branch Number
Cheque Account
Savings Account
Transmission Account
Bond Account
Other (Please Specify)
ID Number
Passport Number
Company Registration Number / /
*CC Registration
*Please include CC/CK where applicable
Practise Number
Bank stamp
It is hereby confirmed that this details have been verified
against the following screens
ABSA-CIF screen
FNB- Hogans system on the CIS4/CUPR
STD Bank-Look-up-screen
Nedbank- Banking Platform under the Client Details Tab
Business
Area Code Telephone Number Extension
Home
Area Code Telephone Number Extension
Fax
Area Code Fax Number
Cell
Cell Code Cell Number
Email Address
Adress of Rural Development and Land Reform
Office where form is submitted from
/ / / /Date (dd/mm/yyyy) Date (dd/mm/yyyy)
NB: All relevant fields must be completed
Account Type
Account Name
Supplier Account Details
Contact Details
Contact Person:
Supplier Signature Departmental Official
Print Name Print Name
Rank
Page 28 of 37
SBD 2
TAX CLEARANCE CERTFICATE REQUIREMENTS
It is a condition of bid that the taxes of the successful bidder must be in order, or that satisfactory arrangements have been made with South African Revenue Service (SARS) to meet the bidder’s tax obligations. 1 In order to meet this requirement bidders are required to complete in full the attached form TCC 001
“Application for a Tax Clearance Certificate” and submit it to any SARS branch office nationally. The Tax Clearance Certificate Requirements are also applicable to foreign bidders / individuals who wish to submit bids.
2 SARS will then furnish the bidder with a Tax Clearance Certificate that will be valid for a period of 1 (one) year
from the date of approval. 3 The original Tax Clearance Certificate must be submitted together with the bid. Failure to submit the original
and valid Tax Clearance Certificate will result in the invalidation of the bid. Certified copies of the Tax Clearance Certificate will not be acceptable.
4 In bids where Consortia / Joint Ventures / Sub-contractors are involved, each party must submit a separate Tax Clearance Certificate.
5 Copies of the TCC 001 “Application for a Tax Clearance Certificate” form are available from any SARS branch
office nationally or on the website www.sars.gov.za. 6 Applications for the Tax Clearance Certificates may also be made via eFiling. In order to use this provision,
taxpayers will need to register with SARS as eFilers through the website www.sars.gov.za. Jeyrel:\Mdk416-SBD2 tax clearance
Page 29 of 37
TCC 001 TAX CLEARANCE
Application for a Tax Clearance Certificate
Name/Legal name(Initials & Surname or registered name)
Surname
Particulars of applicant
Purpose
Particulars of representative (Public Officer/Trustee/Partner)
Trading name (if applicable)
First names
VAT registration no
Customs code
Income Tax ref no
Income Tax ref no
PAYE ref no
SDL ref no
UIF ref no
Page 1 of 2
ID/Passport no
ID/Passport no
Company/Close Corp. registered no
4
7
L
U
Telephone no
Telephone no
Physical address
Physical address
Postal address
E-mail address
E-mail address
Fax no
Fax no
C O D E
C O D E
N U M B E R
N U M B E R
C O D E
C O D E
N U M B E R
N U M B E R
If “Good standing”, please state the purpose of this application
Select the applicable option Tenders Good standing
Page 30 of 37
Page 2 of 2
Particulars of the 3 largest contracts previously awarded
Particulars of tender (If applicable)
Audit
Date started
I the undersigned confirm that I require a Tax Clearance Certificate in respect of Tenders or Goodstanding.
I hereby authorise and instruct to apply to and receive from SARS the applicable Tax Clearance Certificate on my/our behalf.
Appointment of representative/agent (Power of Attorney)
Date finalised Principal Contact person Telephone number Amount
Name of representative/ agent
Name of applicant/ Public Officer
Signature of representative/agent
Signature of applicant/Public Officer
Date
Date
Expected duration of the tender
Estimated Tender amount
Are you currently aware of any Audit investigation against you/the company?If “YES” provide details
Tender number
R ,
year(s)
C C Y Y
C C Y Y
M M
M M
D D
D D
YES NO
Notes:
1. It is a serious offence to make a false declaration.
2. Section 75 of the Income Tax Act, 1962, states: Any person who
(a) fails or neglects to furnish, file or submit any return or document as and when required by or under this Act; or
(b) without just cause shown by him, refuses or neglects to-
(i) furnish, produce or make available any information, documents or things;
(ii) reply to or answer truly and fully, any questions put to him ...
As and when required in terms of this Act ... shall be guilty of an offence ...
3. SARS will, under no circumstances, issue a Tax Clearance Certificate unless this form is completed in full.
4. Your Tax Clearance Certificate will only be issued on presentation of your South African Identity Document or Passport (Foreigners only) as applicable.
Declaration
I declare that the information furnished in this application as well as any supporting documents is true and correct in every respect.
Page 31 of 37
SBD 4
DECLARATION OF INTEREST 1. Any legal person, including persons employed by the state¹, 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 bid (includes a price quotation, advertised competitive bid, limited bid or proposal). In view of possible allegations of favouritism, should the resulting bid, 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 bidder or his/her authorised representative declare his/her position in relation to the evaluating/adjudicating authority where-
- the bidder is employed by the state; and/or - the legal person on whose behalf the bidding document is signed, has a relationship with
persons/a person who are/is involved in the evaluation and or adjudication of the bid(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 bid.
2. In order to give effect to the above, the following questionnaire must be completed and
submitted with the bid. 2.1 Full Name of bidder or his or her representative: …………………………………………………………. 2.2 Identity Number: ………………………………………………………………………………………………… 2.3 Position occupied in the Company (director, trustee, shareholder²): …………………………………….. 2.4 Company Registration Number: ………………………………………………………………………..……. 2.5 Tax Reference Number: ………………………………………………………………………………….……… 2.6 VAT Registration Number: ………………………………………………………………………………....
2.6.1 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.
¹“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. ²”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.
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2.7 Are you or any person connected with the bidder YES / NO presently employed by the state? 2.7.1 If so, furnish the following particulars:
Name of person / director / trustee / shareholder/ member: ……....……………………………… Name of state institution at which you or the person connected to the bidder is employed : ……………………………………… Position occupied in the state institution: ……………………………………… Any other particulars: ………………………………………………………………
……………………………………………………………… ………………………………………………………………
2.7.2 If you are presently employed by the state, did you obtain YES / NO
the appropriate authority to undertake remunerative work outside employment in the public sector?
2.7.2.1 If yes, did you attached proof of such authority to the bid YES / NO
document? (Note: Failure to submit proof of such authority, where applicable, may result in the disqualification of the bid.
2.7.2.2 If no, furnish reasons for non-submission of such proof:
……………………………………………………………………. ……………………………………………………………………. …………………………………………………………………….
2.8 Did you or your spouse, or any of the company’s directors / YES / NO trustees / shareholders / members or their spouses conduct business with the state in the previous twelve months?
2.8.1 If so, furnish particulars:
………………………………………………………………….. ………………………………………………………………….. …………………………………………………………………...
2.9 Do you, or any person connected with the bidder, have YES / NO any relationship (family, friend, other) with a person employed by the state and who may be involved with the evaluation and or adjudication of this bid?
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2.9.1If so, furnish particulars. ……………………………………………………………... …………………………………………………………..….
………………………………………………………………
2.10 Are you, or any person connected with the bidder, YES/NO aware of any relationship (family, friend, other) between
any other bidder and any person employed by the state who may be involved with the evaluation and or adjudication of this bid?
2.10.1 If so, furnish particulars.
……………………………………………………………… ……………………………………………………………… ………………………………………………………………
2.11 Do you or any of the directors / trustees / shareholders / members YES/NO
of the company have any interest in any other related companies whether or not they are bidding for this contract?
2.11.1 If so, furnish particulars: ……………………………………………………………………………. ……………………………………………………………………………. …………………………………………………………………………….
3 Full details of directors / trustees / members / shareholders. Full Name Identity
Number Personal Tax Reference Number
State Employee Number / Persal Number
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4 DECLARATION
I, THE UNDERSIGNED (NAME)………………………………………………………………………
CERTIFY THAT THE INFORMATION FURNISHED IN PARAGRAPHS 2 and 3 ABOVE IS CORRECT. I ACCEPT THAT THE STATE MAY REJECT THE BID OR ACT AGAINST ME IN TERMS OF PARAGRAPH 23 OF THE GENERAL CONDITIONS OF CONTRACT SHOULD THIS DECLARATION PROVE TO BE FALSE. ………………………………….. ..…………………………………………… Signature Date …………………………………. ……………………………………………… Position Name of bidder
May 2011
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SBD 8
DECLARATION OF BIDDER’S PAST SUPPLY CHAIN MANAGEMENT PRACTICES
1 This Standard Bidding Document must form part of all bids invited. 2 It serves as a declaration to be used by institutions in ensuring that when goods
and services are being procured, all reasonable steps are taken to combat the abuse of the supply chain management system.
3 The bid of any bidder may be disregarded if that bidder, or any of its directors
have-
a. abused the institution’s supply chain management system; b. committed fraud or any other improper conduct in relation to such system; or c. failed to perform on any previous contract.
4 In order to give effect to the above, the following questionnaire must be completed and submitted with the bid.
Item Question Yes No 4.1 Is the bidder or any of its directors listed on the National Treasury’s database as
companies or persons prohibited from doing business with the public sector? (Companies or persons who are listed on this database were informed in writing of this restriction by the National Treasury after the audi alteram partem rule was applied).
Yes
No
4.1.1 If so, furnish particulars:
4.2 Is the bidder or any of its directors listed on the Register for Tender Defaulters in terms of section 29 of the Prevention and Combating of Corrupt Activities Act (No 12 of 2004)? To access this Register enter the National Treasury’s website, www.treasury.gov.za, click on the icon “Register for Tender Defaulters” or submit your written request for a hard copy of the Register to facsimile number (012) 3265445.
Yes
No
4.2.1 If so, furnish particulars:
4.3 Was the bidder or any of its directors convicted by a court of law (including a court outside of the Republic of South Africa) for fraud or corruption during the past five years?
Yes
No
4.3.1 If so, furnish particulars:
4.4 Was any contract between the bidder and any organ of state terminated during the past five years on account of failure to perform on or comply with the contract?
Yes
No
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4.4.1 If so, furnish particulars:
SBD 8
CERTIFICATION
I, THE UNDERSIGNED (FULL NAME)…………………………………………………
CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS TRUE AND CORRECT.
I ACCEPT THAT, IN ADDITION TO CANCELLATION OF A CONTRACT,
ACTION MAY BE TAKEN AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE.
………………………………………... ………………………….. Signature Date
………………………………………. ………………………….. Position Name of Bidder
Js365bW
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