VENDOR APPLICATION FORM VENDOR NAME - Midvaal 13 Nov 2013_2.pdf · must submit a separate original tax clearance certificate. ... Company Registration ... potential vendor must indicate

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PLEASE ALLOW 10 – 15 WORKING DAYS FOR EVALUATION AND VERIFICATION OF VENDOR FORMS. KINDLY CONTACT THE ABOVE PERSONS FOR YOUR VENDOR NUMBER

REPORT FRAUD, THEFT & CORRUPTION RAPPORTEER BEDROG, DIEFSTAL & KORRUPSIE

TLALEHO BOKIRIKIRI BOSHODU LE BOBODU

0860-268-624

ZERO TOLERANCE TO FRAUD

SUPPLY CHAIN MANAGEMENT UNIT

P O Box 9 Enquiries: Tel: (016) 360-7453/7481 Meyerton, 1960 Fax: 086 614 8317 E-mail: [email protected] or [email protected] Website: www.midvaal.gov.za

VENDOR NR: OFFICE USE ONLY

VENDOR APPLICATION FORM

VENDOR NAME:

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Section 112 (f), (i), (j), (k) and (l) of the Municipal Finance Management Act, (act 56 of 2003) requires that a Municipality must have measures in place to comply with the prescribed regulatory framework for municipal supply chain management. You are kindly requested to complete this document accurately and in full, as the information contained herein are required for the following purposes: To enable Midvaal Local Municipality to compile a database of registered suppliers;

To support Midvaal Local Municipality with the implementation of a system of preferences as

required by the Preferential Procurement Policy Framework Act (No 5 of 2000) and its’ regulates as amended from time to time.

Listing Criteria for accreditation of approval as a Midvaal Local Municipality vendor:

1. Failure to complete the form in full may result in the supplier not being considered for the

awarding of any orders or contracts by the Midvaal Local Municipality. 2. It is a condition of bidding that a vendor’s taxes must be in order, or satisfactory

arrangements must have been made with the Receiver of Revenue to meet his/her tax obligations. In bids where consortia/joint ventures/sub-contractors are involved, each party must submit a separate original tax clearance certificate. Please note that no copies, certified or scanned tax clearance certificates will be accepted.

3. Declaration of interest. 4. Document stamped and signed by bank and Commissioner of oath. 5. Construction companies must be registered with the CIDB. 6. Registered Company as required by applicable legislation. 7. Not on any register for tender defaulters at any Government tender list or Midvaal Local

Municipality list. Should you require any assistance with regard to this form please contact Mr F. Powell at (016) 360-7496 during office hours Monday to Friday, 07:30 – 16:00.

These forms must be completed in full and returned to:

The Supply Chain Management Unit – Finance

Mitchell Street Meyerton, 1962

or posted to:

Midvaal Local Municipality Attention: Supply Chain Management Unit - Finance

P O Box 9 MEYERTON, 1961

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Please complete the form in full in print, using black ink to ensure that all information is legible. Forms that are not readable or incomplete will be rejected.

KINDLY KEEP COPIES OF ALL SUBMITTED FORMS AND ALL DOCUMENTS FOR

YOUR RECORDS AS NO COPIES WILL BE MADE BY MIDVAAL LOCAL MUNICIPALITY

KINDLY KEEP THE FOLLOWING IN MIND WHEN COMPLETING THE VENDOR APPLICATION FORMS

Mandatory Fields: Certain fields and documents are mandatory to certain business types

only. Please ensure that all fields relevant to your business type, which is marked “Mandatory Field”, have been completed, and if a field is not applicable to your business, clearly mark it as N/A (Not applicable).

Required documents: Please refer to the attached table following pages to determine the

mandatory supporting documentation required by your business. Please ensure that all certified copies of Mandatory documents are attached.

Completion of questions: All questions must be answered clearly with yes, no, or N/A. Do not

leave any fields open. Please respond to all questions in the application form as incomplete forms will not be processed.

Certified Documents: Please ensure that a Commissioner of Oaths has certified your

Company Registration Document, Proof of Shareholding Certificates, ID documents or other documents relevant to your business type. The stamp of certification should be on the front of the document.

Copies of documents: Please keep copies of the registration form and all supporting

documentation submitted, for your own records and to ensure that all data is maintained and up to date on a continuous basis.

Owners, shareholders and Partners: Ensure that the percentage of ownership amount o

100% and that every field is fully completed for each of the business owners.

Certificate of correctness: Kindly ensure that the Certificate of Correctness is signed and dated once all the required documents and information have been submitted.

Collection Points: Completed registration forms and supporting documentation can be

delivered to the address on the registration form.

Processing of registration: Your fully completed application will be processed, and once verified, will be approved and your will be issued with a Supplier Database Vendor Code to be used in all future communication with all of the above role players. This letter of verification will be dispatched to the correspondence details supplied on the application form. Please note that this administration process will take a minimum of 5 days, once your registration has been included on the Midvaal Vendor Database, your details will be accessible to the procurement department in Midvaal.

Business Opportunities: Kindly note that qualifying as a vendor does not in any way

guarantee any persons, company, service provider vendor, etc. any business from the Midvaal Local Municipality every time a bid or requests for quotations/proposals are requested.

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Amendments: Please notify Midvaal immediately of any changes to the verified information submitted, including liquidations/sequestrations of owners or company.

Queries: Should you have any queries or need assistance in completion of the application forms, kindly contact the Supply Chain Management Unit at (016) 360-7400.

Should a company have more than one office, each office must submit a separate form,

unless the point of transaction is centralized in the company’s head office and should clearly be stated as such in the document.

Please note that the key facilities in the database are classified as commodities and each

potential vendor must indicate the commodity/ commodities in which it would like to register for procurement processes. Vendors may register a maximum of three commodities only.

The main objective of this process is to enhance transparency and equality on the part of

Midvaal and to facilitate effective communication with its vendors.

Applications must be delivered by hand and must be fully completed with all the relevant documentation attached.

Midvaal Reserves the right to perform an audit to confirm or verify any of the statements

supplied in the applications form.

The Occupational, Health and Safety Act will apply for all works, goods and services rendered to Midvaal Local Municipality and by submitting this vendor and commodities; the vendor agrees to adhere to all the regulations and its amendments throughout the full process of delivering goods and services to MLM at any one time, project of term contract.

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PLEASE KEEP COPIES OF REGISTRATION FORM AND ALL DOCUMENTATION SUBMITTED DOCUMENTS

REQUIRED BUSINESS TYPE WHERE TO FIND

DOCUMENTS Sole Proprietor

Close Corporations

& Private companies

Partnerships Public Company

Business Trust Non-profit organization

(NPO)

Certified copies of company registration

N/A CK1/CK2 Partnership agreement

CM3 Trust agreement Section 21 Registrar of Close Corporations &

Companies Certified copies of Proof of ownership

N/A CK1/ CK2 Partnership agreement

Share-holding CM3

Trustees details: Letter of Attorney

Auditor’s letter - no

shareholding

Registrar of Close Corporations &

Companies Proof of banking Bank

statement/ cancelled cheque

Bank statement /cancelled

cheque

Bank statement/ cancelled cheque




Branch of bank where account is

held

Income tax Business owner

For the company/ cc

For the partnership

For the company

For the trust For the NPO Receiver of Revenue (SARS)

Original Tax Clearance

Business owner

For the company/cc

For the partnership

For the company

For the trust For the NPO Receiver of Revenue (SARS)

PAYE If staff are employed

If staff are employed





Receiver of Revenue (SARS)

VAT Registration (above R1 m annual t/over)

If registered for vat






Receiver of Revenue (SARS)

UIF Certificate If staff are employed






Department of labour

Workman’s Compensation







Department of labour

Security Officer’s Board

If applicable – security industry






Security Service Industry

Regulatory Authority

Construction Industry Development Board

If applicable- construction

industry

If applicable- construction industry





Construction Industry

Development Board

Certified proof of disability

If owner is disabled






Clear certified copy of ID

Owners Identity

document

Owners Identity

document

Owners Identity

document

Owners Identity

document

Owners Identity document

Owners Identity

document CONTACT DETAILS

REGISTRAR OF COMPANIES SOUTH AFRICA (CIPC) Zanza Building, 116 Proes Street, Pretoria: Tel: 086 100 2472 Fax: 086 517 7224 web: www.cipc.co.za

DEPARTMENT OF LABOUR (LABOUR CENTRE) Southern Life Building, Cnr Joubert and Merriman Streets, Vereeniging: Tel: (016) 430-0000 Fax: (016) 422 4109

SOUTH AFRICAN REVENUE SERVICES (SARS) Cnr Merriman & Joubert Street, Vereeniging: Tel: (016) 422 3621 Web: www.sars.gov.za

DEPARTMENT OF LABOUR (COMPENSATION FUND) Compensation House, Cnr Hamilton and Soutpans Streets, Pretoria Tel: 086 010 5350 Fax: (012) 326-1570/357-1772 Web: www.labour.gov.za

SECURITY SERVICE INDUSTRY REGULATORY AUTHORITY (PSIRA) 481 Belvedere Street, Arcadia Tel: (012) 337-5500 Fax: (012) 326-6128

CONSTRUCTION INDUSTRY DEVELOPMENT BOARD (CIDB) Block N&R, SABS Campus, 2 Dr Lategan Rd, Groenkloof, Pretoria, South Africa Web: www.cidb.org.za Tel: (012) 482-7200/086 100 2438 Fax: (012) 349 8986/086 681 9995

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BUSINESS PARTICULARS AS PER CIPC http://www.cipc.co.za

NAME OF BUSINESS: TRADING NAME:

HOLDING COMPANY:

LANGUAGE:

TYPE OF SUPPLIER

(PLEASE TICK RELEVANT BOXES)

COMPANY REGISTRATION NUMBER:

COMPANY VAT NUMBER:

LOCALITY OF HEAD OFFICE:

LOCALITY OF BRANCH:

MUNICIPAL AREA:

CURRENCY:

BEE ACCREDITATION LEVEL

BEE EXPIRY DATE

TAX CLEARANCE EXPIRY DATE

DISABLED % PLEASE SUBMIT PROOF

WOMEN %

YOUTH %

LOCALLY SITUATED YES/NO (ADDRESS ____________________________________________)

HOW WOULD YOU LIKE TO RECEIVE YOUR CORRESPONDENCE FROM US? * (INVITE TO QUOTE ONLY. BID DOCUMENTS ONLY AVAILABLE BY E-MAIL, WEB PAGE, HARD COPY OR FAX) Fax: Fax No.: _______________________________ Post: Postal Address: _________________________________________________ E-mail: e-mail: _________________________________ SMS*: Cell No.: _______________________________

DISTRIBUTOR

MANUFACTURER

MANUFACTURER & DISTRIBUTOR

SOLE PROVIDER (PLEASE SUBMIT PROOF OF SUCH)

SERVICE PROVIDER

OTHER (PLEASE SPECIFY):

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BUSINESS PHYSICAL ADDRESS: ______________________________________ ______________________________________

BUSINESS POSTAL ADDRESS _____________________________________ _____________________________________

TELEPHONE NO:

CELL NO:

E-MAIL ADDRESS:

FAX NO:

WEB-PAGE ADDRESS:

PREFERRED CONTACT PERSON

CONTACT TYPE NAME AND SURNAME √

SALES

ACCOUNTS/QUERIES

DIRECTOR

SIGNATORY PERSONS DETAILS

FULL NAME:

JOB TITLE:

DATEOF BIRTH:

ID NUMBER:

DATE OF COUNCIL/BOARD RESOLUTION (Kindly attached resolution)

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COMMODITY GROUP

PLEASE NOTE THAT ANY VENDOR MAY ONLY REGISTER FOR A MAXIMUM OF THREE (3) COMMODITY GROUPS

(PLEASE TICK RELEVANT BOXES)

INTEREST CATEGORY

NO CATEGORY √ 1 PRODUCTS

2 CONTRACTED SERVICES

3 PROFESSIONAL SERVICES

4 LEGAL SERVICES

5 GENERAL BUILDING AND MAINTENANCE

6 WORKSHOP SERVICES: VEHICLE, PLANT AND EQUIPMENT: repairs, maintenance, COF’s,

routine services, etc

7 VEHICLE, PLANT AND EQUIPMENT SPARES

REGION

KINDLY INDICATE IN WHICH REGION YOUR COMPANY IS SITUATED: Please note that preference will be given to companies situated in the Midvaal area.

FREE STATE

GAUTENG

KWAZULU-NATAL

LIMPOPO

MPUMALANGA

NORTH-WEST

NORTHERN CAPE

NORTHERN PROVINCE

PROCURE DEFAULT REGION

WESTERN CAPE

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COMMODITY CATEGORIES – GOODS AND SERVICES (PLEASE TICK RELEVANT BOXES) ONLY 3 PER VENDOR

NO: DESCRIPTION √ NO: DESCRIPTION √

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Consulting Services: Attorney/legal; valuators/debt collection; Engineering Consultants including, electrical, civil, mechanical, structural, architectural, land survey, quantity surveying, urban, town planning, environmental management, project management, etc.

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Electrical: Low tension under 1000 volt Medium Volt up to 30 000 volt High tension upto 240 000 volt

2 Glass suppliers, fitters and repairs 28 Sound recording and reproducing equipment

3 Alarm and Security systems and services 29 Groceries and Toiletries

4 Bearings and seals (vehicle, plant and equipment) 30 Alcohol and beverages

5 Nuts and bolts (vehicle, plant and equipment) 31 Library: Specialised services, equipment and accessories (e.g. books, shelving, library stationery, etc).

6 Building material e.g. sand, stone, bricks, cement, paint, sealer, adhesive and accessories, etc)

32 Medical care (medicines, surgical equipment and accessories, etc)

7 Chemicals – pool, degreaser and other 33 Stage, sound and lighting equipment and services

8 General cleaning supplies (e.g. brooms, mops, cleaning products, black bags, etc) 34 Public event management services

9 Protective and uniform clothing, general and specialised 35 Waterproofing and membranes

10 Communication equipment and accessories (two way radios, intercom systems, etc) 36 Photographic equipment and services

11 Computer equipment, software and accessories (conform to SITA provisions) 37 Refrigeration, air conditioning, air circulating

12 Containers and packaging supplies 38 Scaffolding and ladders

13 Electric and electronic components (e.g. breakers, pole transformers) 39

Roads and storm water items (pipes, connections, extension, culverts, kerbing, etc.)

14 Electrical consumables (general maintenance items) 40 Tar products (Bitumen, cold mix, pre-mix)

15 Electrical insulation, wires and brushes (incl. Electrical cable, fibre optic cable) 41 Steel: bar, wire, mesh and tubing

16 Electrical apparatus: switchgear, mini substations and transformers 42 Stationery (including printer cartridges,

paper, etc)

17 Supply, delivery and registration of vehicle, plant and equipment (new or demo) 43 Hire of vehicles, plant and equipment

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18 Filters (e.g. vehicles plant and equipment, swimming pools, air conditioners, etc) 44 Signage and accessories (public signs,

vehicles signs, banners, etc)

19 General hardware (batteries, torches, globes, nails, screws, hammers, etc) 45 Printing and binding (letterheads,

notices, business cards, pamphlets etc)

20 Firearms, ammunition and accessories 46 Hand tools and machine tools (all)

21 Shooting range and firearm licencing facilities 47 Traffic signs and poles

22 Fuel and lubricants (e.g. petrol, diesel, oil, 2 stroke oil, brake fluid, grease, paraffin) 48 Water and sewer items (pipes,

connections, fittings, valves, etc)

23 Office and other furniture 49 Waste disposal (septic tank services)

24 Irrigation, gardening equipment and accessories 50 Plumbing services and accessories

25 Fire, rescue and safety equipment 51 Water purification systems and accessories

26 Corporate gifts and clothing 52 Labour Services (hiring or temporary employees)

53 Professional accredited training services (in-house/external – SETA/SAQA provisions) 60

Fire extinguisher services: supply, delivery, installation, inspections, repairs and maintenance

54 Agricultural supplies and services (e.g pest control, weed killing, fertilizer, plants and trees)

61 Arts and crafts (artistic works, designs, ornaments, sculptures and artist pieces)

55 Chemical waste disposal 62 Roof specialists: roofing, repairs and maintenance

56 Light bars and sirens 63 Catering services: in house, external service provider, restaurants, pubs, “tuisnywerheid”

57 Concrete products: kerbing, manholes, etc. 64 Interior decorators

58 Security services (guards and response) 65 Workshop, repairs and maintenance to vehicles, plant and equipment (please complete the Workshop section below as well)

59 Fencing and palisades: steel, concrete, electrical, mesh, etc 66 Other (please specify)

OTHER: _______________________________________________________________________________ _____________________________________________________________________________________________

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65. WORKSHOP: REPAIRS AND MAINTENANCE TO VEHICLES, PLANT AND EQUIPMENT NO: DESCRIPTION √ NO: DESCRIPTION √

1 Auto electrical services/repairs (including alarm and security systems) 18 Strip, quote and reassemble (only per hour

rates will be accepted)

2 Differential including transmission, gearbox services, repairs and maintenance 19 Wheels/tyres (fitting, alignment, tire repair

balancing, etc)

3 Petrol engine/vehicle services/repairs 20 Vehicle tracking systems and services

4 Spares provider (please specify if necessary) 21 Body work repairs (panel-beating, spray

painting, etc)

5 Radiators: supply, installation, repairs and maintenance 22 Exhaust and tow bar installations, repairs

and maintenance

6 Generators: supply, delivery, installation, repairs and maintenance 23 Brakes and air brakes maintenance,

services and repairs

7 Hydraulic services/repairs 24 Interior (upholster etc) services/repairs

8 Safety test and certification of vehicle mounted ladders, cherry pickers (including electrical resistance tests).

25 Testing and certification of other specialised items: e.g. pressure vessels, lifting equipment, gas cutting items, cranes, ladders, slings, chain slings, etc

9 Testing and certification of specialised fire and emergency equipment 26 Testing, calibration and certification of

weighbridges

10 Testing and certification of specialised traffic accessories and equipment 27 Testing, calibration of test equipment

11 Installation of vehicle sound equipment 28 Air conditioning services/repairs 12 Batteries: vehicle, plant and equipment 29 Diesel engine/vehicle services/repairs

13 Vehicle registration services 30 Grass cutters, lawnmowers etc services/repairs

14 Glass replacement services on vehicle, plant and equipment 31 Prop shaft and cv joint installation, services,

repairs and maintenance

15 Plant vehicle – general services/repairs 32 Tractors: supply, service, repairs and maintenance

16 Towing Services – small vehicles, plant and equipment 33 Towing Services – heavy duty vehicles,

plant and equipment

17 Cleaning and valet services 34 Other (please specify)

OTHER: _______________________________________________________________________________ _____________________________________________________________________________________________

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BUSINESS PARTICULARS

SALES AND ACCOUNTS DEPARTMENTS

Sales Department:

Contact Name: _____________________ Cell No: _____________________ Email Address _____________________ Telephone Fax _____________________

Accounts Department:


NB: All fields are mandatory.

The questionnaire will require the following information and all suppliers must attach corresponding documentation as proof thereof:

With what legislative bodies is your company registered with to render such services as

indicated by you? _________________________________________________________________________ _________________________________________________________________________

What make of vehicles is your company approved/accredited to work on (attach letter from

agents)?

___________________________________________________________________________ ___________________________________________________________________________

Is your firm registered and does it have a business license(s)? Yes / No

Please attach lay-out of workshops, plant and equipment.

All the personnel’s qualifications (mechanics, etc) please attach proof. Name Qualification

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Details all trade associations in which you have a membership: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

What is the average turnaround time for the various services your company offers? (Please indicate the kind of service and turnaround time)

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Please indicate what your company’s labour price is for a strip and quote. R________/hour (Please break down into sections to compare competitively with other suppliers)

It may be required from your company to allow other companies to visit your site to “visit and

quote” on the vehicle, plant or equipment your company has stripped.

Does your company have any objection to the above? _____________________ If yes please give reasons.

_________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Kindly indicate availability of spares in the workshops and or from agents.

_________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

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Please indicate company procedures and turnaround time for emergency services and call-outs.

_________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________

Is your company accredited with any insurance companies for repairs and maintenance to

vehicles, plant and equipment? If so, kindly attach details. Kindly indicate which of the following council owned vehicles your company is qualified/accredited and approved to repair, maintain or service. Please note that vehicles under maintenance plan and warranty will be sent to the agents.

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(Please tick relevant boxes)

TYPE: MAKE OF VEHICLE YOUR COMPANY IS ACCREDITED FOR

Accredited

YES/NO

Repair

YES/NO

Maintain

YES/NO

Service

YES/NO

C.O.F.

YES/NO

TRACTOR

LDV 2 X 4 (single or double)

LDV 4 X 4 (single or double)

SKIP LOADER

TRAILERS

FRONT END LOADER

TIPPER TRUCK

TRUCKS

COMPACTOR TRUCK

MOTOR VEHICLE - SEDAN

COMPRESSOR

CRANE TRUCK

FIRE TANKER PUMP E ONE

FIRE TANKER PUMP FORD

TANKER PUMP

TANKER TRUCK SUCTION TANKER

TRAILER DRAIN CLEANING EQUIPMENT RODS

MINI LOADER MACHINE EXCAVATING SKIPSTEER

CASE

SEWER PUMP

LOWBED TRAILER

SMALL TRAILERS

MACHINE BOMAG

GRADERS

WACKER

MINI LOADER MACHINE EXCAVATING BOBCAT

TRENCHER

WATER TANKERS

FIRE ENGINE PIERCE

CHERRY PICKER

BACK HOE LOADER

VEHICLE MOUNTED LADDERS

CRANES

OTHER

BANKING (COMPULSORY)

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BANK NAME:

BRANCH CODE:

ACCOUNT HOLDERS NAME:

ACCOUNT TYPE

ACCOUNT NUMBER

*DATE STAMP OF BANK CERTIFIED AS CORRECT

CONFIRMATION OF BANK DETAILS BY BANK OFICIAL: Initials and Surname (Bank official): ____________________________________________ Telephone number (Bank official) : (________) ____________________ Signature (Bank official): _______________________________________

SIGNATURE AUTHORITY (to be completed by the company’s accredited person) *Signature _________________________________ duly authorized to sign on behalf of

________________________________________________ (Name of organization) address

___________________________________________________________________________

Telephone no. (________) ____________________ Date _________________________

* Mandatory AUTHORISATION FOR ELECTRONIC TRANSFER OF FUNDS (EFT) TO VENDOR’S BANK

ACCOUNT

PAYMENT METHOD CHEQ

ELECTRONIC

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PLEASE COMPLETE IN BLOCK LETTERS

SURNAME/COMPANY NAME:

FIRST NAMES/COMPANY ACCOUNT HOLDER:

ADDRESS:

TELEPHONE: FAX:

MOBILE: EMAIL:

BANK: ACCOUNT #:

BRANCH: BRANCH #:

TYPE OF ACCOUNT: CHEQUE SAVINGS TRANSMISSION

I, the undersigned hereby authorise the Midvaal Local Municipality to credit my account via EFT as afore mentioned with the amount payable/due to specified beneficiary for goods and services rendered. Please Note: That if a cancelled cheque is not attached, an official stamp should be obtained from the bank to confirm the information given above. _____________________ _______________________________ DATE SIGNATURE

FOR OFFICE USE ONLY – MIDVAAL LOCAL MUNICIPALIT

CAPTURED BY

DATE OF CAPTURE

SIGNITURE PLEASE NOTE THAT ALL FIELDS ARE MANDATORY AND ALL FIELDS NOT MANDATORY

MUST BE CLEARLY MARKED NOT APPLICABLE (N/A)

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KINDLY ENSURE THAT THE FOLLOWING DOCUMENTS (WHERE APPLICABLE) ARE ATTACHED TO YOUR APPLICATION FORM

CATEGORY YES NO N/ACERTIFIED WORKMAN’S COMPENSATION CERTIFICATE CERTIFIED REGIONAL COUNCIL REGISTRATION CERTIFIED VAT 103 CERTIFIED P.A.Y.E./SDL/UIF (EMP 103) CERTIFIED COMPANY REGISTRATION DOCUMENTS CERTIFIED PROOF OF OWNERSHIP/SHAREHOLDER CERTIFICATE ORIGINAL VALID TAX CLEARANCE CERTIFICATE PROOF OF BANK DETAILS (not older than three months) CERTIFIED COPY OF B-BBEE CERTIFICATE OR LETTER FROM ACCOUNTING OFFICER (REGISTERED ACCOUNTANT/IRBA/SANAS)

CERTIFIED DISABILITY DOCUMENTS CERTIFIED SECURITY OFFICER’S BOARD REGISTRATION MUNICIPAL ACCOUNT (not older than three months – up to date) LABOUR BROKER ARE YOU FAMILIAR WITH THE OCCUPATIONAL, HEALTH AND SAFETY ACT AND ITS REGULATIONS?

SECTION 16.1 APPOINTMENT (OHS ACT, 85 OF 1993) (Compulsory for all construction/repairs and maintenance categories)

SECTION 16.2 APPOINTMENT (OHS ACT, 85 OF 1993) (Compulsory for all construction/repairs and maintenance categories)

PLEASE NOTE THAT PROOF OF THE ABOVEMENTIONED DOCUMENTS IS REQUIRED TO ENSURE SUCCESSFUL REGISTRATION ON THE SUPPLIER DATABASE. IN THE EVENT OF A DOCUMENT NOT BEING REQUIRED PLEASE TICK THE N/A BOX. KINDLY REFER TO PAGE 3 FOR DETAILED INFORMATION WITH REGARD TO DOCUMENTS REQUIRED

MIDVAAL LOCAL MUNICIPALITY INDEMNITY

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1. The Contractor hereby agrees to indemnify, hold harmless and defend Midvaal Local Municipality and their officers, employees, agents and representatives, from and against the following liabilities arising as a result of the execution of the work:

1.1 Any liability with regard to claims by governmental authorities or others for non-

compliance by Contractor of any Act of Parliament, law, ordinance, regulation or by-law made by a lawful authority provided that such compliance therewith was required for the execution of the Contract or at Law.

1.2 Any liability arising from actual or alleged public or private nuisance arising out of

negligent acts or omissions to act of Contractor or its Subcontractors, or of their employees.

1.3 Any liability arising from loss or damage to Contractor and/or Subcontractor’s

equipment and their other property on site. 1.4 Any liability arising from claims with regard to the death of/or injury or sickness or

disease to Contractor’ employees or the death of/or injury or sickness or disease to third parties.

1.5 Any liability arising from any loss of/or damage to property belonging to a third party. 1.6 Any liability arising from actual or asserted infringement or improper appropriation or

use of patents, copyrights, proprietary information or know- how in respect of the work designed by/or under the responsibility of the Contractor.

1.7 Any liability arising from the death or injury or loss or damage to property of third

parties or Midvaal Local Municipality’s property as a result of the negligent acts or omissions of contractors or its subcontractor’s employees.

1.8 Contractor shall indemnify Midvaal Local Municipality against all claims,

proceedings, damages and costs of whatsoever nature arising out of contravention of environmental legislation.

I, _______________________________________the undersigned (duly authorised to sign) hereby declare that I have read and understood the abovementioned and agree to all the above. COMPANY: _____________________________________________________________ ADDRESS: _____________________________________________________________ TEL: _______________________ CELL: ___________________________ DATE: ______________________ SIGNATURE: _____________________

COMPANY REGISTRATION (COMPULSORY)

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NB: Documentary proof must be provided where applicable (Please mark N/A if not applicable)

TYPE OF COMPANY CERTIFIED COPY √ * REGISTRATION NUMBER PUBLIC COMPANY LTD Certificate of Incorporation (Cm3) and

Regional Council Registration Number

PRIVATE COMPANY (PTY) LTD

Certificate of Incorporation (CM3) and Regional Council Reiteration Number

CLOSE CORPORATION CC CK1 Document or CK 2 if Applicable and Regional Council Registration Number

SOLE PROPRIETOR Regional Council Registration Document PARTNERSHIP Regional Council Registration Document

and Partnership Agreement

BUSINESS TRUST Regional Registration Document and Registration Document

OTHER (IF JOINT VENTURE)

Copy Of Regional Council Registration and Registration Document

FORMS CERTIFIED COPY √ * REGISTRATION NUMBER

VAT Registration (VAT 103) - If you qualify for vat exemption, please attached a vat exemption document - Not applicable to all companies, please specify if N/A

PAYE - P.A.Y.E. Document (See Point 8) - Not applicable to all companies, please specify if N/A

UNEMPLOYMENT INSURANCE FUND DOCUMENTS

Not applicable to all companies, please specify if N/A

WORKMAN’S COMPENSATION FUND DOCUMENTS


SECURITY OFFICERS BOARD REGISTRATION NO


INCOME TAX REGISTRATION

- If you qualify for income tax exemption, please attach an income tax exemption document- - Not applicable to all companies, please specify if N/A

TAX CLEARANCE CERTIFICATE

- Original of a valid Tax Clearance Certificate must be supplied - No e-mailed, faxed, certified or scanned copies will be accepted.

• If not applicable to your company, please specify N/A. BUSINESS PARTICULARS

8SALES AND ACCOUNTS DEPARTMENTS

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Sales Department:


Accounts Department:


NB: All above fields are mandatory.

CORE BUSINESS OPERATION

(Mark with X in applicable fields)

Prime Contractor Sub-Contractor * Labour-only contractor Supplier Manufacturer Labour Agency Professional Services Construction (CIDB) Education, Development &

Training Service Provider Sole supplier (please attach supporting documents to this application for verification purposes)

Other, please specify: _______________________________________________________ __________________________________________________________________________ * Sub-contractor: less than 25% generated turnover as prime contractor. Please note that sub-contracting more than 25% of the total contract value must be to verified BBBEE companies in collaboration with the PPPFA – Regulations of 2011. Proof of such must be attached in the form of a BBBEE verification and level certificate. CIDB CIDB Number Expiry Date CIDB Grading Application of

registration Date Registration Date

ANNUAL AVERAGE TURNOVER

Indicate annual average turnover excluding Value Added Tax during the past three years: 10

DETAILS OF ACCOUNTING OFFICER AS CONTEMPLATED IN SECTION 60(4) OF THE

CLOSED CORPORATIONS ACT, ACT NO 69 OF 1984 (CCA)

R

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Please submit full details and supporting documents.

PREVIOUS BUSINESS INFORMATION

Did your business exist under a previous name? YES / NO

If yes, what name did it trade under?

Previous business registration number?

BUSINESS INFORMATION

The following table must be completed in order to establish whether a business can be classified as an SMME in terms of the National Small Business Act 102 of 1996. Indicate the sector by ticking the appropriate block in column

SMME Status BBBEE Enterprise

Small EME: Exempted Micro Enterprises Medium QSE: Qualifying Small enterprise Micro Established

PROUDLY SOUTH AFRICAN CAMPAIGN

Does your company support the government’s initiative to support locally manufactured and distributed products?

YES/NO

If so please indicate and provide proof of such: _____________________________________________________________________________ _____________________________________________________________________________

LABOUR BROKERS

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Please answer the questions by marking the appropriate column with an “X”. Please do not leave out any questions relating to your special circumstances. (Only to be completed if wishing to register as a labour broker).

YES/NO

1. Do you render the service to the MLM through a Company, Close Corporation or Trust?

2. Are you an Independent Contractor?

3. Are you a Labour Broker? If yes = taxable unless IRP30 certificate is received. If no, see next questions)

4. Are the services personally rendered by a person who is a connected person (shareholder, member, trustee, beneficiary, relative of the afore-mentioned, etc) in relation to the Company/ Close Corporation or trust? If yes, see question 5, 6, 7, 8 and 9. If no = not subject to employees tax)

5. Does the entity employ four of more full-time employees? (Other than shareholders, members or connected persons) who are on a full-time basis engaged in the business of rendering services to clients? (This implies that the tea lady and gardener would not be considered in determining the full-time staff members rendering services to clients).

6. Would the person who is rendering the service be regarded as an “employee” of the MLM?

7. Is the person who is rendering the service subject to the control or supervision of the MLM as to the manner in which duties are performed or as hours of work?

8. Do the amounts paid in respect of services rendered include earnings that are payable at regular, daily, weekly, monthly or other intervals/ (This is normally on the basis that you charge your client for the person in question’s salary plus commission for your service.)

9. Does the Company/Close Corporation or Trust, during its financial year, receive or anticipate to receive more than 80% of the income for this specified service from the MLM? If yes to any one of questions 6, 7, 8, or 9, then taxable, except if an IRP30 certificate can be submitted. If no to all four questions (6, 7, 8, and 9) = Not subject to employees tax.

Subject to employees tax

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COMPLETE THE FOLLOWING OWNERSHIP/DIRECTORS/TRUSTEES DETAILS AND SUPPLY CERTIFIED COPY OF SHAREHOLDER CERTIFICATES OR PROOF OF OWNERSHIP/DIRECTORS/TRUSTEES MUST BE SUPPLIED

FULL NAME AND SURNAME OF OWNERS, DIRECTORS OR

TRUSTEES

ID NO.

ARE YOU OR ANY OF YOUR OWNERS, DIRECTORS,

TRUSTEES REGISTERED ON NATIONAL TREASURIES’

DATABASE FOR RESTRICTED SUPPLIERS

www.treasury.gov.za

* CAPACITY D/P/M/R/O

BEE ACCREDITED

LEVEL

SANAS – GAUTENG

ACCREDITING COMPANY

DATE OF ACCREDITATION

Multiple copies of this page may be submitted if required. However, should the list be large, kindly attach a certified list to this page)

* CAPACITY

DIRECTOR D

PARTNER P

MEMBER M

PROPRIETOR R

OTHER O

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Do you share any of your business facilities? Yes / No

If yes, which facilities are shared? ________________________________________

With whom do you share facilities? (Name of firms / individuals)

___________________________________________________________________________ ___________________________________________________________________________

Is the firm registered or does it have a business license(s)? Yes / No

If yes, give details and quote relevant reference numbers and dates. ___________________________________________________________________________ ___________________________________________________________________________

Details all trade associations in which you have a membership: ___________________________________________________________________________ ___________________________________________________________________________

Does your company outsource or sub-contract works to other companies? (kindly refer pages 34 – 37 of this form for details)

Yes / No

If yes, kindly indicate the % that would be outsourced or sub-contracted if more than 25%.

NAME OF SUB-CONTRACTOR/

OUTSOURCING COMPANY

% OUTSOURCED/SUB-

CONTRACTED

B-BBEE LEVEL OF THIS SUPPLIER/CONTRACTOR/SERVICE

PROVIDER

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PREVIOUS CONTRACT OR TENDERING EXPERIENCE (COMPULSORY)

Kindly supply details of references of previous works rendered. Attach a detailed list should this page not be sufficient.

1. Employer/Department

Contact Person

Contact Number

Estimated Contract Value in Rand ___________________

Year Awarded: _________________

Year Completed / Still in Progress: ______________________________

Proof documents attached? Yes/ No


Contact Person

Contact Number


Year Awarded: _________________




Contact Person

Contact Number


Year Awarded: _________________



In terms of section 37(2) of the Occupational Health and Safety Act 1993 (Act 85 of 1993) as amended the mandatory (contractor) hereby acknowledges that he is an employer in his own right. He undertakes to determine all risks associated with the work he is required to perform and to determine and implement all cautionary measures to mitigate or remove such risk. The mandatory will take all necessary steps to ensure compliance with the Occupational Health and Safety Act 1993. Where the mandatory is found not to comply with the requirements of the occupational Health and Safety Act the MLM or its representative will be able to stop the activities of the mandatory, without any cost to the MLM, until such time as the mandatory complies with the requirements of the Act. 13\

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CERTIFICATION OF CORRECTNESS OF INFORMATION SUPPLIED IN THIS DOCUMENT

I/We the undersigned is/are duly authorised to do so on behalf of the firm certify that: 1. The information supplied is correct. 2. All copies of relevant information are attached. 3. The HDI points claimed are correct and based on owners/shareholders who are actively

involved in the day to day management of the enterprises. 4. I take note that payment will be effected 30 days after delivery was affected if delivered

with an original invoice. 5. If I am classified as a dependant service provider/labour broker as stated in the fourth

schedule of the Income Tax act I hereby authorise the MLM to deduct PAYE and supply me with a yearly IRP 30 (only if no valid Labour Broker Certificate can be supplied).

__________________________________ ______________________ SIGNATURE OF AUTHORISED PERSON DATE

PERSONAL INFORMATION IN BLOCK LETTERS

NAME:

SURNAME:

TELEPHONE: CAPACITY: ON BEHALF OF: (SUPPLIERS NAME)

Signed and sworn to before me at ____________________________________ on this the ________ day of _________________.by the Deponent, who has acknowledged that he/she knows and understands the contents of this Affidavit, that it is true and correct to the best of his/her knowledge and that he/she has no objection to taking the prescribed oath, and that the prescribed oath will be binding on his/her conscience.

COMMISSIONER OF OATH

SIGNATURE: ____________________ DATE: ______________________

STAMP

MUST BE DATE STAMPED AND SIGNED BY A COMMISSIONER OF OATHS

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GENERAL PRE-CONDITIONS FOR CONSIDERATION OF QUOTATIONS AND BIDS Disclosure of benefits 5. (1) A staff member of a municipality who, or whose spouse, partner, business associate

or close family member, acquire or stands to acquire any direct benefit from a contract concluded with the municipality, must disclose in writing full particulars of the benefit to the council.

(2) This item does not apply to a benefit which a staff member, or a spouse, partner,

business associate or close family member, has or acquires in common with all other residents of the municipality.”

Section 168 of the Local Government Municipal Finance Management Act, Act 56 of 2003 made the regulations as set out in the Schedule - Supply Chain Management Regulations and indicates as follows: “Part 2: Acquisitions Management 13. General pre-conditions for consideration of quotations and bids

A municipality may not consider a written quotation or bid unless the provider who submitted the quotation or bid –

(a) Has furnished the municipality with their: - Full name - Identification number or company or other registration number; - Tax reference number and VAT registration number (if applicable – Annual turnover

more than R300 000-00) (b) has authorised the municipality to obtain a tax clearance from the South African

Revenue Services that the provider’s tax matters are in order (power of attorney- Annexure “A”); and

(c ) has indicated: (i) Whether he or she is in the service of the sate, or has been in the service of the state (municipality) in the previous twelve months; (ii)if the provider is not a natural person, whether any of its directors,

managers, principal shareholders or stakeholders is in the service of the state or has been in the service of the state in the previous twelve months; or

(iii) Whether a spouse, child or parent of the provider or of a director, manager,

shareholder or stakeholder referred to in subparagraph (ii) above is in the service of the state, or has been in the service of the municipality in the previous twelve months.”

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All quotations submitted must reflect the following information:

- On letterhead - Business street/physical address - Business telephone and fax number - Quotation reference number - Vat Registration Number (where applicable) - Tax reference number

All original tax invoices submitted for payment must reflect the following information:

- On letterhead - Business street/physical address - Business Telephone and fax number - Quotation reference number - Company Vat Registration Number (if applicable) - Midvaal Local Municipality’s VAT registration number: 4700193503 - Tax reference number - Company registration number

“Part 4: Other matters 45. Awards to close family members of persons in the service of the State (Municipality) -

The notes to the annual financial statements must disclose particulars of any award of more than R2 000 to a person who is a spouse, child or parent of the a person who is in the service of the state, or has been in the service of the state in the previous twelve months, including –

(a) The name of the person; (b) The capacity in which that person is in the service of the state; and

(c) The amount of the award

Policy on Doing Business with DA controlled Governments The Federal Executive resolved as follows: That no office-bearer or member of the professional staff of the Party, or any company, partnership, close corporation or similar juristic entity in which such office-bearer or member of the professional staff has an interest, may tender for or contract to provide any goods or services to any DA controlled government. For the purposes of this resolution: “office-bearer” means any public representative or member of the Federal Executive, a provincial executive, a provincial management committee, a regional executive or a constituency executive; “an interest” means that the office bearer or member of the professional staff has a 5% of more stake; and “member of the professional staff” means any person who has an employment contract with the Party, and includes any person who is employed by the Party but who is paid by an organ of

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state, but does not include any person paid a gratuity or honorarium for services rendered to the Party. You are kindly requested to disclose to council any information relating to the above issues by completing and signing the declaration form below, In lieu of the above, your application to become a service provider on the Midvaal Local Municipality data base will be finalised and a vendor number will be issued to all accredited prospective suppliers and service deliverers. Please contact Mrs C Kearns or Mr F Powell at (016) 360-7572 should you have any further queries.

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DECLARATION OF INTEREST (COMPULSORY)

1. No bid will be accepted from persons in the service of the state¹. 2. Any person, having a kinship with persons in the service of the state, including a blood

relationship, may make an offer or offers in terms of this invitation to bid. In view of possible allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons connected with or related to persons in service of the state, it is required that the bidder or their authorised representative declare their position in relation to the evaluating/adjudicating authority.

3. A Person who is an advisor or consultant contracted with the municipality.

4. In order to give effect to the above, the following questionnaire must be completed and submitted with the bid.

4.1 Full Name of bidder or his or her representative:_______________________________ 4.2 Identity Number: 4.3 Position occupied in the Company (director, trustee, shareholder²): _______________ 4.4 Company Registration Number: __________________________________________ 4.5 Tax Reference Number: _________________________________________________ 4.6 VAT Registration Number:

_______________________________________________ 4.7 The names of all directors / trustees / shareholders members, their individual identity � numbers and state employee numbers must be indicated in paragraph 4 below. 4.8 Are you presently in the service of the state? YES / NO If so, furnish particulars. _______________________________________________________________ _______________________________________________________________ 4.9 Have you been in the service of the state for the past twelve months? YES / NO If so, furnish particulars. _______________________________________________________________ _______________________________________________________________

4.10 Do you have any relationship (family, friend, other) with persons in the service of the

state and who may be involved with the evaluation and or adjudication of this bid? YES / NO

If so, furnish particulars. _______________________________________________________________ _______________________________________________________________

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4.11 Are you, aware of any relationship (family, friend, other) between any other bidder and any persons in the service of the state who may be involved with the evaluation and or adjudication of this bid?

YES / NO If so, furnish particulars. _______________________________________________________________ _______________________________________________________________

4.12 Are any of the company’s directors, trustees, managers, principle shareholders or

stakeholders in service of the state? YES / NO

If so, furnish particulars. _______________________________________________________________ _______________________________________________________________ 4.13 Are any spouse, child or parent of the company’s directors, trustees, managers,

principle shareholders or stakeholders in service of the state? YES / NO

If so, furnish particulars. _______________________________________________________________ _______________________________________________________________ 4.14 Do you or any of the directors, trustees, managers, principle shareholders, or

stakeholders of this company have any interest in any other related companies or business whether or not they are bidding for this contract.

YES / NO If so, furnish particulars. _______________________________________________________________ _______________________________________________________________ 5. Full details of directors / trustees / members / shareholders.

FULL NAME IDENTITY NUMBER STATE EMPLOYEE NUMBER

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1. Please note that the The Federal Executive of the DA resolved as follows:

“That no office-bearer or member of the professional staff of the Party, or any company, partnership, close corporation or similar juristic entity in which such office-bearer or member of the professional staff has an interest, may tender for or contract to provide any goods or services to any DA controlled government. For the purposes of this resolution: “office-bearer” means any public representative or member of the Federal Executive, a provincial executive, a provincial management committee, a regional executive or a constituency executive; “an interest” means that the office bearer or member of the professional staff has a 5% of more stake; and “member of the professional staff” means any person who has an employment contract with the Party, and includes any person who is employed by the Party but who is paid by an organ of state, but does not include any person paid a gratuity or honorarium for services rendered to the Party.”

6.1 Are you or your company an office-bearer by means of any public representative or

member of the Federal Executive, a provincial executive, a provincial management committee, a regional executive or a constituency executive?


6.2 Do you or your company have an interest by means that the office bearer or member

of the professional staff has a 5% of more stakes? YES / NO

If so, furnish particulars. _______________________________________________________________ _______________________________________________________________

6.3 Are you or your company a member of the professional staff by means any person

who has an employment contract with the Party, and includes any person who is employed by the Party but who is paid by an organ of state, but does not include any person paid a gratuity or honorarium for services rendered to the Party?


1 MSCM Regulations: “in the service of the state” means to be –

(a) A member of – - any municipal council; - any provincial legislature; or - the national Assembly or the national Council of provinces;

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(b) a member of the board of directors of any municipal entity; (c) an official of any municipality or municipal entity; (d) an employee of 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); (e) a member of the accounting authority of any national or provincial public entity; or (f) an employee of Parliament or a provincial legislature. ² Shareholder” means a person who owns shares in the company and is actively involved in the management of the company or business and exercises control over the company.

CERTIFICATION I, THE UNDERSIGNED (NAME) ___________________________________________ CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS CORRECT.

I ACCEPT THAT THE STATE MAY ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE.

_______________________________ ____________________________ SIGNATURE DATE

____________________________ ____________________________ POSITION NAME OF BIDDER

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WITHOUT PREJUDICE TO ANY LEGAL OR CONTRACTUAL RIGHTS OR REMEDIES MLM MAY HAVE, A SUPPLIER AND / OR ITS DIRECTORS / OWNERS / MEMBERS WILL BE

RESTRICTED FROM DOING ANY BUSINESS WITH MLM, IF THE SUPPLIER: 1. Provides false or incorrect information in this application.

2. Promises, offers or gives or attempts to promise, offer or give to an official, employee or any

other person related to MLM any bribe, commission, gift, loan, advantage or any other consideration whatsoever.

3 Fails to testify, or make their employees available to testify in any criminal, misconduct

procedures against any government official MLM. 2. Fails to report in writing within 24 hours after any suspected misconduct by any government

official of the MLM, including but not limited to attempts to bribe or commits any unethical behaviour to the Head of the Department.

3. Makes any statements to the media concerning MLM or on information obtained whilst

working for MLM, without written authority from government.

6. Promotes or incites labour unrest amongst government officials on or off government property.

7. Is the direct or indirect cause of disciplinary or criminal action taken against any

government official of MLM. 8. Cause racial conflict on any government property, or property occupied by

government. 9. Is in unauthorised possession of, or removes or attempt to remove any property belonging

to or which is under the control of the government, government officials, other suppliers or visitors of MLM.

10. Is found guilty by a competent court, or has paid an admission of guilt, in respect of any criminal offence which can breach a necessary trust relationship between MLM and the supplier, or may offend the general public.

11. Prevent or obstruct any government official of MLM or someone appointed by government to gain access to premises for the purpose of inspecting records or material relevant to the functions, duties, services, or products of the supplier to government.

12. Wilfully or negligently damages any government property, or directly or indirectly causes

any loss of government assets. 13. Makes a false statement or representation, which relates to or arises from its contractual

duty to MLM. 14. Falsifies any document or records which relates to its duties to DEAT. 15. Builds up a history of poor performance to MLM. 16. Knowingly gives false evidence during criminal or departmental proceedings related to its

contractual obligations to MLM.

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17. Has a bad credit history or track record with other suppliers or MLM that could damage the trust relationship.

18. Is in debt with the Receiver of Revenue or has a bad track record with the Receiver of

Revenue. 19. Fails to or has failed to comply with any conditions of an agreement or performs or has

performed unsatisfactorily under an agreement with MLM. PREFERENTIAL PROCUREMENT POLICY FRAMEWORK ACT, ACT 5 OF 2000 – REGULATIONS 2011 DATED 08 JUNE 2011 EFFECTIVE 07 DECEMBER 2011. The amended PPPFA regulations have been promulgated in the Government Gazette No: 9544, Vol. 552 dated 08 June 2011 – No. 34350 where the scoring values for a government tender has been amended to include BBBEE status level of contribution on the 80/20 as follows:

B-BBEE Status Level of Contribution

80/20 90/10 Please tick applicable grading

1 20 10

2 18 9

3 16 8

4 12 5

5 8 4

6 6 3

7 4 2

8 2 1

Non-compliant contributor 0 0 NOTICE 354 OF 2009 GAZETTED IN THE GOVERNMENT GAZETTE NO. 32094 DATED 09 APRIL 2011 PUBLISHED THE FOLLOWING: DEPARTMENT OF TRADE AND INDUSTRY SECTION 14 OF THE BROAD BASED ECONOMIC EMPOWERMENT ACT, ACT NO. 53 OF 2003 provides that: (a) from 1st August 2009, only BEE verification certificates issued by Accredited Verification

Agencies or Verification Agencies that are in possession of a valid pre-assessment letter from South African National Accreditation Systems will be valid;

(b) despite the provision in paragraph (a) above, all verification certificates issued by non-accredited verification agencies prior to the date of this publication, will remain valid for 12 months from the date of issue;

(c) the period of validity of the certificates contemplated in paragraph (a) above, will be 12

months from the date of issue; and (d) this Notice is effective from the date of this publication.

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Kindly visit the South African National Accreditation Systems website for the list of accredited BBEEE Verification Agencies (www.sanas.co.za). No BEE certificates will be accepted from non-accredited BBEEE Verification Agencies and will render a vendor and tender invalid. I, _______________________ in my capacity as ______________ being the authorised signatory, hereby declare that I have submitted a valid BBBEE level graded certificate graded by a SANAS accredited verification agency. ___________________________ ________________________ CERTIFICATE NUMBER: DATE ISSUED: _________________________________ ________________________ NAME AND SURNAME DATE _____________________ SIGNATURE Vendor application form/ck 13 November 2013