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Enquiries: E-mail:

Tel No:

SUPPLIER DATABASE REGISTRATION

FOR 2010 TO 2011 FINANCIAL YEAR

NAME OF SERVICE PROVIDER: _________________________________ (To be completed by supplier)

FOR OFFICIAL PURPOSES

Name of Evaluator from SCM: ____________________________________ Persal No: ______________ Signature: ____________________

Date:

Entity Maintenance No: ________________ Captured by: ________________ Persal No: ______________ Signature: ________________ Date: ______________

APPLICATION ACCEPTED

APPLICATION

REJECTED

DoJ & CD Supplier Number

Verified & Captured on Su pplier Database by : ________________ Persal No: ______________ Signature: ____________________ Date:

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SUPPLIER DATABASE REGISTRATION FOR 2010 TO 2011 FINANCIAL YEAR

The Department of Justice and Constitutional Development (DoJ&CD) is an outwardly focused, customer-centered government department mandated to uphold and protect the Constitution and Rule of Law in the interest of a safer and more secure South Africa. DoJ & CD, pursuant to the provisions of the Public Finance Management Act (PFMA), Act 1 of 1999) read with CIPRO Supply Chain Management Policy invites service providers to register on DoJ & CD’s database of suppliers/services as official vendors and suppliers for the 2010 to 2011 Financial Year. Suppliers and service providers currently registered as vendors on the DoJ & CD database should also re-apply for considerations to be re-registered on the DoJ & CD vendor/supplier database. Enterprises owned by HDI”s (Historically disadvantaged Individuals), Women, Youth, People with Disabilities and BEE’S (Black Economic Empowerment) are encouraged to apply. A list of commodities requirements are enlisted in the supplier database application form. Prospective suppliers/service providers may apply to be enlisted on the supplier database for a maximum of five (5) commodities specific as per their principle business, other than those suppliers on SITA transversal contracts. Failure to comply with this condition will invalidate the applications and would not be evaluated further. Supplier Database registration forms are obtainable from: Website: www.justice.gov.za Physical Address: Momentum Centre Postal address: Private Bag X81 329 Pretorius Street Pretoria Pretoria 0001 0001 Enquiries should be forwarded to:

Tel No: E-mail Address Fax No. N.Skosana 012 357 8583 nskosana@justice.gov.za 086 640 3113 I. Thusi 012 357 8291 ithusi@justice.gov.za 086 688 5470 M. Karabo 012 357 8198 kmasilo@justice.gov.za 086 642 3759 M.S.Bassier 012 315 4545 Sbassier@justice.gov.za 086 641 2053

Closing date: 31 October 2010 at 11:00 Completed registration forms may be hand delivered or posted to the above mentioned postal address on or before closing date and time for attention: The Director: Supply Chain Management (DoJ & CD)

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SUPPLIER REGISTRATION FORM

IMPORTANT NOTES Please read carefully before completion of registration form

� To be completed by all vendors seeking registration as an approved supplier; � The supplier registration form must be completed in full and be signed, and forwarded to the National Department of Justice and Constitutional Development at Pretoria with all supporting documentation ; � A company profile which also addresses the evaluation criteria set out in this document must

accompany the registration form but will not be accepted as substitute for the application form – all fields on application form MUST be completed by applicant;

� Successful applicants will be contacted via fax and/or email and must therefore submit an operating fax number and/or email address; failure to comply will result in excluding the supplier from the data base; � Only successful suppliers will be notified in writing on their application been accepted; � Supplier must comply with all the registration-criteria for registration to be finalized - failure to

do so will result in the application being declined. � All shareholders/ Directors/ Members and in case of one-man concern, please furnish identity number plus

copy of identity documents Research & Development contact details:

Telephone: 012 357 8198 / 012 315 1682

Fax number: 086 687 7698

Email: jypresearchanddevelopment@justice.gov.za

1. SUPPLIER DETAILS(All fields are mandatory)

Details:

Company Name: (Orders will be issued In this name )

Trading Name:

Registration Number:

ID number:

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VAT Number:

Income Tax Number

Telephone Number:

Fax Number:

Website Address:

Postal Address:

Physical Address:

Banking Details

Bank Name:

Branch Name:

Account Type:

Branch Code:

Account Number:

Main Contact:

Name:

Surname:

Position:

Telephone Number:

Facsimile Number:

Cellular Number:

E-mail Address:

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2. SUPPLIER GROUPING DETAILS: (Please mark with an X the relevant box)

Public Company (Ltd)

(Attach a Certified copy of Incorporation (CM3)

Private Company (Pty) Ltd

(Attach a Certified copy of Incorporation (CM3))

Closed Corporation (cc)

(Attach a Certified copy of (CK1 & CK2))

Sole Proprietor

(Attach a Certified copy of ID Document)

Partnership

(Attach a Certified copy of Partnership Agreement)

Trust

(Attach a Certified copy of Trust Document)

Foreign Company

(Attach a Certified copy of Incorporation)

Joint Venture

(Attach a Certified copy of all Members ID Documents

and joint venture agreement signed by all parties)

Consortium

(Attach a Certified copy of all Members ID Documents

and consortium agreement signed by all parties)

Section 21 Company

Government / Parastatals

Other (specify)

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3. PREFERENCE POINTS CLAIMS

List all partners and shareholders (compulsory)

Name Position Citizenship ID Number

% Ownership

Note: where owners are themselves a company or partnership, owners of the holding firm must be identified. HDI Ownership Status: Please read notes below very carefully Instructions and Definitions: (Please read carefully before completing HDI Ownership Status) �Owned: Having all the customary elements of ownership, including the right of decision-making and sharing all the risks and profits commensurate with the degree of ownership interests as demonstrated by an examination rather than the form of ownership arrangements. �Historically Disadvantaged Individuals (HDI): For the purpose of registering as a supplier for the Department, the refutable presumption shall be made that SA citizens who fall into population groups that had no franchise in national elections prior to the introduction of the 1983 and 1993 constitution are Historically Disadvantaged Individuals. It is incumbent on individuals to demonstrate their claims to fall into such population groups on the basis of identification and association with and recognition by the members of such a group. �Women: A female person who is a SA citizen. �Establishment of HDI / Women Equity Ownership in a enterprise: Equity ownership shall be equated to the percentage of an enterprise which is owned by individuals, or in the case of a company, the percentage shares that are owned by individuals who are actively involved in the management and daily business operations of the enterprise and exercise control over the enterprise, commensurate with their degree of ownership. Where individuals are not actively involved in the management and daily business operations and do not exercise control over the enterprise commensurate with their degree of ownership, equity ownership may not be claimed.

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HDI Ownership Status: Historically Disadvantaged Individuals (HDI) % %

Women Equity (WE) %

Disabled Individuals (DI) %

4. SMME status of your enterprise

Please use this table to determine the SMME status of your enterprise Please the relevant box in each column

B. Full time paid employees C. Annual Turnover (millions) D. Total Gross asset value (million)

(property excluded) A. Sector

Medium Small Very Small

Micro Medium Small Very Small

Micro Medium Small Very Small

Micro

Agriculture 100 50 10 5 4 2 0.4 0.15 4 2 0.4 0.1 Mining & Quarrying

200 50 20 5 30 7.5 3 0.15 18 4.5 1.8 0.1

Manufacturing 200 50 20 5 40 10 4 0.15 15 3.75 1.5 0.1 Construction 200 50 20 5 20 5 2 0.15 4 1 0.4 0.1 Retail & Motor 100 50 10 5 30 15 3 0.15 5 2.5 0.5 0.1 Wholesale Trade

100 50 10 5 50 25 5 0.15 8 4 0.5 0.1

Catering, Accommodation

100 50 10 5 10 5 1 0.15 2 1 0.2 0.1

Transport, Storage

100 50 10 5 20 10 2 0.15 5 2.5 0.5 0.1

Finance & Business Services

100 50 10 5 20 10 2 0.15 4 2 0.4 0.1

Repairs/Allied Services

100 50 10 5 30 15 3 0.15 5 2.5 0.5 0.1

Communications

100 50 10 5 20 10 2 0.15 5 2.5 0.5 0.1

Other Trade 100 50 10 5 10 5 1 0.15 2 1 0.2 0.1 Commercial Agent

100 50 10 5 50 25 5 0.15 8 4 0.5 0.1

Community & Social Services

100 50 10 5 10 5 1 0.15 5 2.5 0.5 0.1

Personal Services

100 50 10 5 10 5 1 0.15 5 2.5 0.5 0.1

SMME status of your entity Please the relevant box (According to SMME table) (compulsory) Micro

Very small

Small

Medium

Large

I/We confirm that the information provided in paragraph 3 is correct as at this date

Name in print Signature Designation Date

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5. DECLARATION

Verification of information supplied in this document, including attached documents:

I/We, the undersigned, warrants that he / she is duly authorised to do so on behalf of the supplier, certifies that the information supplied including the annexure, is correct and accurate and acknowledge that: If I found that the information supplied is incorrect the Department of Justice and Constitutional Development will disqualify and remove the supplier from our database permanently. TERMS AND CONDITIONS

- The Department of Justice and Constitutional Development can not guarantee business opportunities. All procurement will be subject to the departmental SCM policy, the general conditions of contract, and applicable legislation.

- All suppliers will be subjected to regular performance service review and could be deregistered if service levels are not maintained.

- The validity period of a quotation must be at least 30 ( thirty) days - Certified documents: Please ensure that The Commissioner of Oath has certified your

company registration documents, and other documents. - Original Tax Clearance Certificate - All shareholders/ Directors/ Members and in case of one-man concern, please furnish identity number

plus copy of identity documents - Verification information supplied will perform against third party source such as SARS,

CIPRO, Safety net, etc. - Please notify the Department immediately of any change to the provided information.

- Pleas ensure all fields are completed. Incomplete application forms will not be processed.

Should you have any queries or if you require assistance completing the form please contact the Research and Development unit of Department of Justice on the following numbers: 012 357 8198 / 012 315 1682.

Supplier Name: ____________________________________________________________

________________________________________ __________________________ Signature of Authorised Representative Signatory Name in Print ________________________________________ __________________________ Signatory Capacity: Signatory ID Number: Signed at __________________________ on this ____ day of________________ 20___

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6. SUPPLIER MAINTENANCE FORM: BAS JYP PERSAL

PLEASE WRITE IN BLOCK LETTERS

I/We hereby request and authorise you to pay any amounts, which may accrue to me/us to the credit of my/our account with the mentioned bank.

I/we understand that the credit transfers hereby authorised will be processed by computer through a system known as "ACB - Electronic Fund Transfer Service", and I/we understand that not additional advice of payment will be provided by my/our bank, but that the details of each payment will be printed on my/our bank statement or any accompanying voucher. (This does not apply where it is not customary for banks to furnish bank statements).

I/we understand that the Department will supply a payment advice in the normal way, and that it will indicate the date on which the funds will be made available on my/our account.

This authority may be cancelled by me/us by giving 30 days notice by prepaid registered post.

Please ensure that the information is validated as per required bank screens

I/We understand that bank details provided should be exactly as per the records held by the bank.

I/We understand that the Department will not assume responsibility for any delayed payments, as a result of incorrect information supplied.

Company / Personal Details

Registered Name

Trading Name

Tax Number

VAT Number

Title:

Initials:

First Name:

Surname:

Regional Office Only

Region:

Reference Number:

Contact person:

Contact Telephone number:

Contact Fax number:

Head Office Only Captured By:

Date Captured:

Authorised By:

Date Authorised:

Supplier code:

SUPPLIER NO

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Address Detail

Postal Address

( Compulsory if Supplier )

Postal Code

New Detail

New Supplier information Update Supplier information

Supplier Type: Individual Department Partnership

Company Trust

CC Other ( Specify )

Department Number

Supplier Account Details (Please note that this account MUST be in the name of the supplier. No 3rd party payments allowed).

Account Name

Account Number

Branch Name

Branch Number

Account Type Cheque Account

Savings Account

Transmission Account

Bond Account

Other (Please Specify)

ID Number IF SPOUSE ACC HOLDER

Passport Number

Company Registration Number / /

*CC Registration

*Please include CC/CK where applicable

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Practise Number

Bank stamp

PLEASE ATTACHED A PRINTOUT It is hereby confirmed that this details have been verified

FROM THE BANK against the following screens:

ABSA-CIF screen

FNB-Hogans system on the CIS4

PLEASE PROVIDE BANK STAMP STD Bank-Look-up-screen

PLUS SIGNITURE OF OFFICIAL Nedbank- Banking Platform under Client Details Tab

Contact Details Business

Area Code Extension

Home

Area Code Extension

Fax

Area Code

Cell Cell Code

Email Address:

Contact Person:

Supplier Signature

Print Name

/ / Date (dd/mm/yyyy)

NB: All relevant fields must be completed

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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.1 Eastern Cape Province

Mark with X Mark with X

Aberdeen Port St Johns (Umzimvubu)

Adelaide Queenstown

Albany Qumbu

Albert Somerset East

Alexandria St Marks

Aliwal North Sterkstroom

Barkly East Steynsburg

Bathurst Steytlerville

Bedford Stutterheim

Bizana Tabankulu

Butterworth Tarka

Cathcart Tsolo

Cradock Tsomo

East London Uitenhage

Elliot Umtata

Elliotdale Umzimkulu

Engcobo Venterstad

Flagstaff Victoria East

Fort Beaufort Willowmore

Glen Grey Willowvale (Gatyana)

Graaff-Reinet Wodehouse

Hankey Xalanga (Cala)

Herschel Zwelitsha

Hewu Jansenville

Hofmeyr Joubertina

Humansdorp Keiskammahoek

Idutywa Kentani

Indwe King William’s Town

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Section 7

LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.1 Eastern Cape Province Location Mark with X Location Mark with X

Kirkwood Mount Ayliff

Komga Mount Fletcher

Lady Grey Mount Frere

Libode Mpofu (Stockenström)

Lusikisiki Mqanduli

Maclear Ngqeleni

Matatiele Nqamakwe

Mdantsane Ntabathemba

Middelburg Pearston

Middledrift Peddie

Molteno Port Elizabeth

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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.2 Free State Province Location Mark with X Location Mark with X

Bethlehem Marquard Bethulie Memel Bloemfontein Odendaalsrus Boshof Parys Bothaville Paul Roux Botshabelo Petrusburg Brandfort Petrus Steyn Bultfontein Philippolis Clocolan Reddersburg Dealesville Reitz Dewetsdorp Rouxville Edenburg Sasolburg Edenville Senekal Excelsior Smithfield Fauresmith Springfontein Ficksburg Steynsrus Fouriesburg Thaba ’Nchu Frankfort Theunissen Harrismith Trompsburg Heilbron Ventersburg Hennenman Viljoenskroon Hertzogville Villiers Hobhouse Virginia Hoopstad Vrede Jacobsdal Vredefort Jagersfontein Warden Kestell Welkom Koffiefontein Wepener Koppies Wesselsbron Kroonstad Winburg Ladybrand Witsieshoek Lindley Zastron

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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.3 Gauteng Province Location Mark with X

Alberton Benoni Daveyton Boksburg Brakpan Bronkhorstspruit Cullinan Germiston Heidelberg Johannesburg Regional Office Kempton Park Tembisa Krugersdorp Meyerton Nigel Oberholzer Pretoria ( Include Supply to the National Office) Atteridgeville Pretoria North Mamelodi Randburg Randfontein Roodepoort Soshanguve Springs Vanderbijlpark Sebokeng Vereeniging Westonaria

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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.4 Kwazulu Natal Province (continued on page 17) COURTS IN KZN Mark with X COURTS IN KZN Mark with X Babanango Manguzi Bergville Maphumulo Camperdown Matatiele Chatsworth Melmoth Colenso Mooiriver Dannhauser Mpumalanga Dukuza Msinga Dundee Mtubatuba Durban Mtunzini Emlazi Ndwedwe Ekuvukeni New hanover Empangeni Newcastle Emzumbe Nkandla Enseleni Nongoma Eshowe Nqutu Estcourt Ntuzuma Emnabithi Ongoye Glencoe Paulpietersburg Greytown Phungashe Harding Pietermaritzburg Himeville Pinetown Hlabisa Pongola Hlanganani Port shepstone Howick Richmond Impendle Scottburgh Ingwavuma Simdlagentsha Inkanyezi Stanger Ixopo State attorney Izingolweni Ubombo Kokstad

Umbumbulu

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Section 7

7.4 Kwazulu Natal Province COURTS IN KZN Mark with X COURTS IN KZN Mark with X Kranskop Umzimkhulu Kwamsane Utrecht Ladysmith Verulam Louwsburg Vryheid Madadeni Vulamehlo Magudu Weenen Mahlabatini

LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LOCATED IN THE SPECIFIC PROVINCEWHERE THE GOODS AND/OR SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.5 Limpopo Province

Location Mark with X Location Mark with X Bochum Phalala Bolobedu Pietersburg Dzanani Potgietersrus Ellisras Praktiseer Giyani Ritavi Hlanganani Sekgosese Letaba Sekhukhuneland Lulekani Seshego Malamulele Soutpansberg Mankweng Thabamoopo Mapulaneng Thabazimbi Messina Thohoyandou Mhala Tshilwavhusiku Mokerong Tshitale Mutale Vuwani Namakgale Warmbaths Naphuno Waterberg Nebo Tshitale Phalaborwa

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Section 7

LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHINTHE SPECIFIC PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.6 Mpumalanga Province Location Mark with X Location Mark with X

Amsterdam Lydenburg Amersfoort Mbibana Balfour Mdutjana Barberton Middelburg Belfast Mkobola Bethal Morgenzon Breyten Moutse Carolina Nelspruit Delmas Nkomazi Eerstehoek Nsikazi Ekangala Piet Retief Ermelo Sabie Evander Standerton Graskop Volksrust Groblersdal Wakkerstroom Hendrina Waterval Boven Kriel White River KwaMhlanga

Witbank

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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.7 Northern Cape Location Mark with X Location Mark with X Barkly West Keimoes Britstown Kenhardt Calvinia Kimberley Carnarvon Kuruman Colesberg Noupoort De Aar Olifantshoek Douglas (Herbert) Philipstown Fraserburg Pofadder Galeshewe Port Nolloth Garies Postmasburg Griekwastad (Hay) Prieska Groblershoop Richmond Hanover Springbok (Namakwaland) Hartswater Sutherland Hopetown Upington (Gordonia) Jan Kempdorp Victoria West Kakamas Warrenton Kathu

Williston

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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.8 North West Province Location Mark with X

Bafokeng Bloemhof Brits Christiana Coligny Delareyville Ditsobotla Ganyesa Klerksdorp Koster Kudumane (Tlhaping-Tlharo) Lehurutshe Lichtenburg Madikwe Mankwe Marico Molopo Moretele Odi Potchefstroom Rustenburg Schweizer-Reneke Swartruggens Taung Ventersdorp Vryburg Wolmaransstad

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Section 7 LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. IMPORTANT CONDITION: ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.9 Western Cape Province

Location Mark with X

Location Mark with X

Albertinia Montagu Atlantis Moorreesburg Beaufort West Mossel Bay Bellville Murraysburg Bonnievale Oudtshoorn Bredasdorp Paarl Caledon Piketberg Calitzdorp Porterville Cape Town Prince Albert Ceres Riversdale Clanwilliam Robertson George Simon’s Town Goodwood Somerset West Grabouw Stellenbosch Heidelberg Strand Hermanus Swellendam High Court Cape Town Tulbagh Hopefield Uniondale Khayelitsha Van Rhynsdorp Knysna Vredenburg Kuils River Vredendal Laaiplek Wellington Ladismith Wolseley Laingsburg Worcester Malmesbury Wynberg Mitchells Plain Riversdale

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8. LIST OF COMMODITY SPECIFICS

IMPORTANT NOTICE: PROSPECTIVE SERVICE PROVIDERS MUST MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS. FAILURE TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PROSPECTIVE SERVICE PROVIDERS APPLICATION

No Des cription Mark with an X

No Description Mark

with an X

1 Access Control Systems 29 Computer Consumables

2 Artwork and Painting 30 Computer Hardware, Printer & Components

3 Advertising (in electronic and print media)

31 Computer Networking Contractors

4 Air Conditioning System - Supply and Repairs

32 Computer: Video & Audio Conferencing

5 Anti Virus Software 33 Conferencing Systems 6 Asset Management System Bar-

codes 34 Conference Venues

7 Auctioneers 35 Consulting: Asset Management 8 Audio Visual 36 Consulting: Advertising 9 Awnings 37 Consulting: Auditors

10 Banking Services 38 Consulting: Business Advisor Services

11 Bags, Refuse and Plastic 39 Consulting: Business process analysis and re engineering

12 Binding Services 40 Consulting: Business Strategy 13 Badges Conference, embroidered,

metal 41 Consulting: Contract Law

14 Batteries 42 Consulting: Communication Management

15 Books & Journals 43 Consulting: Communications 16 Blinds 44 Consulting: Competency

Assessment

17 Cashiering Services 45 Consulting: Computer Consulting Services

18 Catering services 46 Consulting: Customer Interface

19 Cellular phone providers 47 Consulting: Customer Satisfaction

20 Change Management 48 Consulting: Emergency & Disaster Management

21 Cleaning Chemicals 49 Consulting: Empowerment Women

22 Cleaning Services 50 Consulting: Employee Health & Wellness

23 Carpets 51 Consulting: Employment Equity and Transformation

24 Clothing General/Protective & Uniforms

52 Consulting: Entrepreneurial Skills

25 Curtaining, Rails and Accessories 53 Consulting: Environmental 26 Clothing General/Protective &

Uniforms 54 Consulting: Executive Coaching

27 Computer Repairs & Maintenance 55 Consulting: Erection Engineers

28 Coffee and vending machines 56 Consulting: Evaluation Assets

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8. LIST OF COMMODITY SPECIFICS

IMPORTANT NOTICE: PROSPECTIVE SERVICE PROVIDERS MUST MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS. FAILURE TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PROSPECTIVE SERVICE PROVIDERS APPLICATION

No Des cription Mark with an X

No Des cription Mark with an X

57 Consulting: Exhibitions 88 Consulting: Litigation

58 Consulting: Exports & Imports 89 Consulting: Library Services 59 Consulting: Financial and accounting

services 90 Consulting: Logistical Services

60 Consulting: Financial and System Integration

91 Consulting: Logistical System

61 Consulting: Financial Administration 92 Consulting Management 62 Consulting: Financial Planning 93 Consulting: Management Tools 63 Consulting: Financial Systems 94 Consulting: Marketing and

Advertising

64 Consulting: Fleet Service Management

95 Consulting: Media Relation

65 Consulting: Forensic Investigation 96 Consulting: Motivational speakers

66 Consulting: Fund Management 97 Consulting: Organizational Design

67 Consulting: Furnaces 98 Consulting: People Transformation

68 Consulting: Geographical Information 99 Consulting: Performance management

69 Consulting: Governance 100 Consulting: Policy Development 70 Consulting: Health Care 101 Consulting: Psychological

Counselling

71 Consulting Human Resources 102 Consulting: Project Management

72 Consulting: Impact Assessment 103 Consulting: Public Relations Management

73 Consulting: Industrial 104 Consulting: Psychological Assessment

74 Consulting: Information technology & Strategy

105 Consulting: Recruitment Services

75 Consulting: Institutional 106 Consulting: Remuneration

76 Consulting: Infrastructure 107 Consulting: Research and Development

77 Consulting: Insurance 108 Consulting: Risk Management

78 Consulting: Interior Decorating 109 Consulting: Skills Development

79 Consulting: Investigation Services 110 Consulting: Survey Research

80 Consulting: Knowledge management 111 Consulting: Talent Management

81 Consulting: Job Evaluation 112 Consulting: Team Building

82 Consulting: Journalism 113 Consulting: Training & Development

83 Consulting: Laboratory 114 Consulting: Tracing Agency & Debt Collection

84 Consulting: Labour Relations 115 Consulting: Website Design 85 Consulting: Landscape Services 116 Corporate Uniform 86 Consulting: Legal Services 117 Courier & Mailing Services 87 Consulting: Legislation Drafting 118 Crockery & Cutlery

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8. LIST OF COMMODITY SPECIFICS MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS

No Des cription Mark with an X

No Des cription Mark with an X

119 Drain cleaning services 156 Gift Promotional 120 Drivers licences permits & Lessons 157 Gardening Services 121 Editing Services 158 Gas and Heating Equipment 122 Electrical Appliances 159 Glassing Contractors 123 Electrical Appliances Household 160 Government Services 124 Electrical Component and Equipment 161 Graphic Design Services 125 Electrical Contractors & Maintenance 162 Government Services 126 Electrical Conveyors 163 Globes, lamps & Fluorescent

tubes

127 Embossing Services 164 Guesthouse & lodges 128 Emergency Medical Suppliers and

Equipment 165 Hardware and Building

Supplies

129 Elevators, Conveyors and Maintenance & repairs

166 Heaters and Heating Equipment

130 Encoding 167 Hiring of Equipment (Sound System & Audio visual)

131 Encrypting software and system 168 Hospitality Service Corporate 132 Engraving Services 169 ID card personalisation

system

133 Engraving Services and Equipment 170 Illustration services 134 Entertainment ( Performers) 171 Imaging Services 135 Entertainment Facilities 172 Illustration services 136 Entertainment Services( Tourists) 173 Industrial chemicals 137 Entertainment Venues and Theatres 174 Information services 138 Envelopes 175 Inspection services 139 Estate Agencies and Consultants 176 Institutes 140 Evacuation Systems 177 Insulation Services 141 Event and Conferencing

Management 178 Intercommunication System

142 Exhibition Centres/Stands 179 Interior Designers 143 Facilitation General Services 180 Interpretation services

magnetic surveys

144 Facilitation Services Conferences 181 Interpreting services languages

145 Fencing Contractors 182 Irrigation contractors 146 Fire Extinguishing 183 Hotel Accommodation 147 Flags and Maps 184 Labels and Labelling services 148 Flooring Contractors 185 Lightning Contractors 149 Florist 186 Locksmiths 150 Footwear 187 Logo: Crockery 151 Framing Services 188 Logo: Design services 152 Franking Machines 189 Logo Engraving 153 Freight Services ( Air, Land and Sea) 190 Licences (Radio & T.V) 154 Furniture removals( Office Furniture) 191 Marketing and

communications Services

155 Gardening Services

192 Market Research

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8. LIST OF COMMODITY SPECIFICS MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS

No Des cription Mark with an X

No Des cription Mark with an X

193 Media Liaison 229 Renovation Services 194 Media/publicity 230 Recording and Transcription

Services

195 Mediator Services 231 Roofing Contractors 196 Mobile homes 232 Safes and Safe removal

Services

197 Network Solutions 233 Sanitary ware 198 Newspapers and Magazines 234 Secretarial Services 199 Number plates 235 Self Defence Training 200 Office Automation Hire 236 Security Equipment - Supply

and Repairs

201 Office furniture 237 Security and Safety services 202 Office Layout Design Services 238 Security Transit 203 Office Buildings Maintenance &

Repairs 239 Seminars

204 Office Machines and Equipment 240 Service Providers Cellular Telephones

205 Organizational Development 241 Signs 206 Packing Material 242 Stationery 207 Paint Supplies 243 Storage facility 208 Partitioning Contractors 244 Storage Systems 209 Paintings 245 Shelves & Shelving 210 Pest Control Services 246 Supply of printed publications 211 Photography Equipment 247 Translation Services 212 Photography Services 248 Transportation service (

including chauffeur services)

213 Plants, Flowers & Decoration 249 Travel agency 214 Printing 250 Telecommunication

Equipment

215 Printing of booklets and publications(design, layout and printing)

251 Telecommunication System

216 Promotional material 252 Tiling Contractors 217 Property Management Services 253 Time and Attendance

Equipment

218 Photography Services 254 Tools and Electrical Mechanical

219 Plumbing Contractors

255 Toilet Paper

220 Professional Bodies & Membership fees

256 Tours and Tourism

221 Publishers 257 Tracking Service Security 222 Quality control services 258 Tracking Service Vehicle 223 Radio Equipment 259 Training Material and

Software

224 Recreation Centers 260 Training Assets Software 225 Recycling Services 261 Training Business Software 226 Refrigeration Equipment and

Repairs 262 Training Business Skills

227 Refuse Conveyers 263 Training Communication 228 Rehabilitation Services Alcohol and

Drug Depend

264 Training: Communication Strategies and Systems

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LIST OF COMMODITY SPECIFICS MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS

No Des cription Mark with an X

No Des cription Mark with an X

265 Training: Community Building 306 Vehicle Audio and Equipment 266 Training: Community Services 307 Vehicle Hiring 267 Training Computer Literacy 308 Vehicle Industry 268 Training: Computer Programming

and Software 309 Vehicle Security and Tracking

System

269 Training: Computer System and Solution

310 Verification Services

270 Training: Conference and Venues 311 Video Recording Services 271 Training: Customer Interactions 312 Venue finders 272 Training: E- Business Strategies 313 Warehouse Services 273 Training: Economic Strategy 314 Waste Disposal 274 Training; Education 315 Waterproofing Contractors 275 Training: Employee Development 316 Window Fitting and Glasses 276 Training: Empowerment Models 317 Web pages and Design 277 Training: Entrepreneurial Skills 318 Web solution Design and

Maintenance

278 Training: Financial Administration 319 Welding Consultants 279 Training: Financial Planning 320 Window Fitting and Glass 280 Training: Financial Systems 321 Wire works General 281 Training: Human Resources 322 Workshop Equipment 282 Training: Information Management 323 Workshop Facilitation 283 Training: IT Services and Strategies 324 Workshop Requisites 284 Training: Labour 325 Writing Articles and Editorials 285 Training: Logistics Systems 326 Writing Services 286 Training: Management 287 Training: Management Tools 288 Training: Multimedia 289 Training: Perfomance Management 290 Training: Personnel Development 291 Training: Project Management 292 Training: Public Relations and

Services

293 Training: Risk Management 294 Training: Secretarial 295 Training: Security Systems 296 Training: Skills Development 297 Training Software Business 298 Training: Stress Management 299 Training: Technical Skills 300 Training: Stress Management 301 Training: Technical Skills 302 Training: Township and Rural

Projects

303 Transcription Services 304 Travel Agency 305 Tyres and Tubes

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PREFERENCE POINTS CLAIM FORM IN TERMS OF THE PREFERENTIAL PROCUREMENT REGULATIONS 2001

PURCHASES

Section 9

This preference form must form part of all bids invited. It contains general information and serves as a claim form for Historically Disadvantaged Individual (HDI) preference points as well as a summary for preference points claimed for attainment of other specified goals NB: BEFORE COMPLETING THIS FORM , BIDDE RS MUST STUDY T HE GENER AL

CONDITIONS, DEFINITIONS AND DIRECTIVES APPLICABLE IN RESPECT OF EQUITY OWNERSHIP BY HIS TORICALLY DISA DVANTAGED IN DIVIDUALS ( HDIs), AS PRESCRIBED IN THE PREFERENTIAL PROCUREMENT REGULATIONS, 2001.

1. GEN ERAL CONDITIONS 1.1 The following preference point systems are applicable to all bids:

- the 80/20 system for requirements with a Rand value of up to R500 000; and

1.2 The value for these quotations is estimated to exceed/not exceed R500 000 and therefore

the 80/20 system shall be applicable. 1.3 Preference points for this bid shall be awarded for:

(a) Price; and (b) Specific contract participation goals, as specified in the attached forms.

1.3.1 The points for this bid are allocated as follows: POINTS

1.3.1.1 PRICE 80 1.3.1.2 SPECIFIC CONTRACT PARTICIPATION GOALS

(a) Histori cally Disadvantaged Individuals: (i) who had no franchise in national elections before the 1983 and 1993 Constitutions 10 (ii) who is a female 7 (iii) who has a disability 3 (b) Other specific goals (goals of the RDP- plus local manufacture) (i) ……. (ii) ……. (iii) ……. (iv) ……. Total points for Price, HDIs and other RDP- goals must not exceed 100 Separate Preference Points Claim Forms will be used for the promotion of the specific goals for which points have been allocated in paragraph 1.3.1.2 (b) above.

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1.4 Failure on the part of a bidder to fill in and/or to sign this form may be interpreted to mean

that preference points are not claimed. 1.5. The purchaser reserves the right to require of a bidder, either before a bid is adjudicated or

at any time subsequently, to substantiate any claim in regard to preferences, in any manner required by the purchaser.

2. GENERAL DEFINITIONS 2.1 “Acceptable quotations ” means any quotation which, in all respects, complies with the

specifications and conditions of bid as set out in the bid document. 2.2 “Quotation” means a written offer in a prescribed or stipulated form in response to an

invitation by an organ of state for the provision of goods, works or services. 2.3 “Comparative price ” means the price after the factors of a non-firm price and all

unconditional discounts that can be utilised have been taken into consideration. 2.4 “Consortium or joint venture” means an association of persons for the purpose of

combining their expertise, property, capital, efforts, skills and knowledge in an activity for the execution of a contract.

2.5 “Contract” means the agreement that results from the acceptance of a bid by an organ of

State. 2.6 “Specific contract participation goals” means the goals as stipulated in the Preferential

Procurement Regulations 2001. 2.6.1 In addition to above-mentioned goals, the Regulations [12.(1)] also make provision for

organs of state to give particular consideration to procuring locally manufactured products. 2.7 “Control” means the possession and exercise of legal authority and power to manage the

assets, goodwill and daily operations of a business and the active and continuous exercise of appropriate managerial authority and power in determining the policies and directing the operations of the business.

2.8 “Disability” means, in respect of a person, a permanent impairment of a physical,

intellectual, or sensory function, which results in restricted, or lack of, ability to perform an activity in the manner, or within the range, considered normal for a human being.

2.9 “Equity Ownership” means the percentage ownership and control, exercised by individuals

within an enterprise. 2.10 “Historically Disadvantaged Individual (HDI)” means a South African citizen

(1) who, due to the apartheid policy that had been in place, had no franchise in national

elections prior to the introduction of the Constitution of the Republic of South Africa, 1983 (Act No 110 of 1983) or the Constitution of the Republic of South Africa, 1993, (Act No 200 of 1993) (“the interim Constitution); and/or

(2) who is a female; and/or

(3) who has a disability:

provided that a person who obtained South African citizenship on or after the coming to effect of the Interim Constitution, is deemed not to be a HDI;

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2.11 “Management” means an activity inclusive of control and performed on a daily basis, by any person who is a principal executive officer of the company, by whatever name that person may be designated, and whether or not that person is a director.

2.12 “Owned” means having all the customary elements of ownership, including the right of

decision-making and sharing all the risks and profits commensurate with the degree of ownership interests as demonstrated by an examination of the substance, rather than the form of ownership arrangements.

2.13 “Person” includes reference to a juristic person. 2.14 “Rand value” means the total estimated value of a contract in Rand denomination that is

calculated at the time of bid invitations and includes all applicable taxes and excise duties. 2.15 “Small, Medium and Micro Enterprises (SMMEs) bears the same meaning assigned to

this expression in the National Small Business Act, 1996 (No 102 of 1996). 2.16 “Sub-contracting” means the primary contractor’s assigning or leasing or making out work

to, or employing another person to support such primary contractor in the execution of part of a project in terms of the contract.

2.17 “Trust” means the arrangement through which the property of one person is made over or

bequeathed to a trustee to administer such property for the benefit of another person. 2.18 “Trustee” means any person, including the founder of a trust, to whom property is

bequeathed in order for such property to be administered for the benefit of another person. 3. ESTABLISHMENT OF HDI EQUITY OWNERSHIP IN AN ENTERPRISE 3.1 Equity ownership shall be equated to the percentage of an enterprise which is owned by

individuals classified as HDIs, or in the case of a company, the percentage shares that are owned by individuals classified as HDIs, who are actively involved in the management and daily business operations of the enterprise and exercise control over the enterprise, commensurate with their degree of ownership.

3.2 Where individuals are not actively involved in the management and daily business

operations and do not exercise control over the enterprise commensurate with their degree of ownership, equity ownership may not be claimed.

4. ADJUDICATION USING A POINT SYSTEM 4.1 The bidder obtaining the highest number of points will be awarded the contract. 4.2 Preference points shall be calculated after prices have been brought to a comparative

basis. 4.3 Points scored will be rounded off to 2 decimal places. 4.4 In the event of equal points scored, the bid will be awarded to the bidder scoring the highest

number of points for specified goals.

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5. POINTS AWARDED FOR PRICE 5.1 THE 80/20 PREFERENCE POINT SYSTEMS A maximum of 80 or 90 points is allocated for price on the following basis: 80/20

minmin180

P

PPtPs

Where Ps = Points scored for price of bid under consideration Pt = Rand value of bid under consideration Pmin = Rand value of lowest acceptable bid 6. Points awarded for historically disadvantaged individuals 6.1 In terms of Regulation 13 (2) preference points for HDI’s are calculated on their percentage

shareholding in a business, provided that they are actively involved in and exercise control over the enterprise. The following formula is prescribed in Regulation 13 (5) (c):

100EP

NOPNEP

Where NEP = Points awarded for equity ownership by an HDI

NOP = The maximum number of points awarded for equity ownership by an HDI in that specific category

EP = The percentage of equity ownership by an HDI within the enterprise or business,

determined in accordance with the definition of HDI’s.

6.2 Equity claims for a trust will only be allowed in respect of those persons who are both trustees and beneficiaries and who are actively involved in the management of the trust.

6.3 Documentation to substantiate the validity of the credentials of the trustees contemplated

above must be submitted. 6.4 Listed companies and tertiary institutions do not qualify for HDI preference points. 6.5 A consortium or joint venture may, based on the percentage of the contract value managed or

executed by their HDI-members, be entitled to preference points in respect of an HDI. 6.6 A person awarded a contract as a result of preference for contracting with, or providing equity

ownership to an HDI, may not subcontract more than 25% of the value of the contract to a person who is not an HDI or does not qualify for the same number or more preference for equity ownership.

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7. BID DECLARATION 7.1 Bidders who claim points in respect of equity ownership must complete the Bid Declaration at

the end of this form. 8. EQUITY OWNERSHIP CLAIMED IN T ERMS OF PARAGRAPH 2.10 ABOVE. POINTS TO

BE CALCULATED FROM INFORMATION FURNISHED IN PARAGRAPH 9.8. Ownership Percentage owned Po ints claimed 8.1 Equity ownership by persons who

had no franchise in the national elections % ………………… 8.2 Equity ownership by women % ……… ………. 8.3 Equity ownership by disabled persons* % …………………

*If points are claimed for disabled persons, indicate nature of impairment (see paragraph 2.8 above) ……………………………………………………………………………………………………………

9 DECLARATION WITH REGARD TO EQUITY 9.1 Name of firm :.............................................................................................

9.2 VAT registration number :.............................................................................................

9.3 Company registration number :…………………………………………………………………

9.4 TYPE OF FIRM

Partnership

One person business/sole trader

Close corporation

Company

(Pty) Limited [TICK APPLICABLE BOX] 9.5 DESCRIBE PRINCIPAL BUSINESS ACTIVITIES …………....................................................................................................................................................

……………….............................................................................................................................................

………………………………………………………………………………………………………… .................

………………………………………………………………………………………………………………………

9.6 COMP ANY CLASSIFICATION

Manufacturer

Supplier

Professional service provider

Other service providers, e.g. transporter, etc. [TICK APPLICABLE BOX]

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9.7 TOTAL NUMBER OF YEARS THE FIRM HAS BEEN IN BUSINESS? ………………..……….. 9.8 List all Shareholders by Name, Position, Identity Number, Citizenship, HDI status and

ownership, as relevant. Information to be used to calculate the points claimed in paragraph 8.

* HDI Status

Name Date/Position occupied in Enterprise

ID Number Date RSA Citizenship obtained

No franchise prior to

elections

Women

Disabled

% of

business / enterprise

owned

*Indicate YES or NO 9.9 Consortium / Joint Venture 9.9.1 In the event that preference points are claimed for HDI members by consortia / joint

ventures, the following information must be furnished in order to be entitled to the points claimed in respect of the HDI member:

Name of HDI member (to be consistent with paragraph 9.8)

Percentage (%) of the contract value managed or executed by the HDI member

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9.10 I/we, the undersigned, who warrants that he/she is duly authorised to do so on behalf of the firm certify that points claimed, based on the equity ownership, indicated in paragraph 8 of the foregoing certificate, qualifies the firm for the preference(s) shown and I / we acknowledge that:

(i) The information furnished is true and correct. (ii) The Equity ownership claimed is in accordance with the General

Conditions as indicated in paragraph 1 of this form. (iii) In the event of a contract being awarded as a result of points claimed as

shown in paragraph 8, the contractor may be required to furnish documentary proof to the satisfaction of the purchaser that the claims are correct.

(iv) If the claims are found to be incorrect, the purchaser may, in addition to

any other remedy it may have - (a) recover costs, losses or damages it has incurred or suffered as a

result of that person’s conduct; (b) cancel the contract and claim any damages which it has suffered

as a result of having to make less favourable arrangements due to such cancellation;

(c) impose a financial penalty more severe than the theoretical

financial preference associated with the claim which was made in the bid; and

WITNESSES: SIGNATURE(S) PROSPECTIVE SUPPLIER

1. ……………………………………… ……………………………………..……

2. ……………………………………… DATE:……………………………….. ADDRESS: ……………………………………….…………………………....

……………………………………….…………………………....

……………………………………….…………………………....

……………………………………….…………………………....

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Section 10

Declaration of Interest 1. Any legal person, including persons employed by the State, or persons who act on behalf

of the State or persons having a kinship with persons employed by the State, including a

blood relationship, may make an offer or offers in terms of the sourcing of quotations. In

view of possible allegations of favouritism, should the resulting quotation, or part thereof, be

awarded to persons employed by the State, or to persons who act on behalf of the State, or

to persons connected with or related to them, it is required that the service provider or his

authorized representative shall declare his or her positions vis-à-vis the evaluating authority

and/or take an oath declaring his or her interest, where -

- The service provider is employed by the State or acts on behalf of the State; and/or

- the legal person on whose behalf the supplier database application form or quotation

is signed, has a relationship with persons/a person who are/is involved with the

evaluation of the quotation(s), or where it is known that such a relationship exists

between the person or persons for or on who's behalf the declarant acts and persons

who are involved with the evaluation of the quotation.

2. In order to give effect to the above, the following questionnaire shall be completed and

submitted with the application to register on the CIPRO supplier database.

2.1 Are you or any person connected with the service provider, employed by the State? (Delete

that is not applicable)

*YES / NO 2.1.1 If so, state particulars.

Name & Surname: ………………………………………………………………………………….

Physical & Postal Address: …………………………………………………………………..……

Tel & number: ……………………………..………. Fax number: …………………………...…

Cell number/s: …………………………………… email address: …..……………………..….

2.2 Do you, or any person connected with the service provider, have any relationship (family,

friend, other) with a person employed in the department concerned and who may be involved

with the evaluation or adjudication of this application or quotations? *YES / NO

2.2.1 if so, state particulars.

Name & Surname: ………………………………………………………………………………….

Physical & Postal Address: ………………………………………………………………………..

Tel & number: ……………………………..………. Fax number:…….………………………...

Cell number/s: ………………………………… email address:……..………………………

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2. 3 Are you, or any person connected with the service provider, aware of any relationship

(family, friend, other) between the service provider and any person employed by the department

concerned who may be involved with the evaluation or adjudication of this applicant or quotations?

*YES / NO

2.3.1 If so, state particulars.

Name & Surname: ………………………………………………………………………………….

Physical & Postal Address:…………………………………………………………………..……

Tel & number: ……………………………..………. Fax number: ………………………………

Cell number/s: …………………………………… email address: …………..…………………

2.4 Are any member or shareholder of the entity has been blacklisted with any Government

Department in the last five years and if so provide the details as an accompanying annexure

to this application. *YES / NO

Failing to provide full disclosure in respect to 2.4 will result in the invalidation of the

prospective service provider’s application.

2.4 All members and shareholders of the entity applying for registration must declare all other

business interest in any other entities, as an accompanying annexure to this application.

Failing to provide full disclosure in respect to 2.5 will result in the invalidation of the

prospective service provider’s application.

DECLARATION

I, THE UNDERSIGNED (NAME)

CERTIFY THAT THE INFORMATION FURNISHED THE SUPPLIER DATA BASE APPLICATION FORM

PARAGRAPHS 2.1 TO 2.3.1 OF THE DECLARATION OF INTEREST IS CORRECT. I ACCEPT THAT THE

DEPARTMENT MAY ACT AGAINST ME IN TERMS OF PARAGRAPH 34 OF THE GENERAL CONDITIONS

OF BID, CONTRACT AND ORDER SHOULD THIS DECLARATION PROVE TO BE FALSE.

_______ Signature Date ___________ __________ ____________ Position Name of Service Provider

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Section 11 DoJ & CD ANTI-CORRUPTION TOLL-FREE HOTLINE

0800 701 701

The aim of the Hotline is to enhance an honest work ethic and simultaneously provide

employees and persons not employed by the Department with a mechanism to bring any

unethical business practices to the attention of management.

DECLARATION

I, THE UNDERSIGNED (NAME)

CERTIFY THAT I AM AWARE OF DoJ & CD ANTI-CORRUPTION TOLL-FREE LINE,

WHERE I CAN FREELY REPORT POSSIBLE CORRUPT ACTIONS BY

SUPPLIERS/SERVICE PROVIDERS/CONTRACTORS OR POSSIBLE CORRUPT

ACTIONS WITHIN THE DEPARTMENT AT ANY TIME AND THAT THE DEPARTMENT

WILL TREAT MY IDENTITY AS STRICTLY CONFIDENTIAL.

Signature Date Position Name of Service Provider

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Section 13

13. SPECIAL CONDITIONS:

1. As per section 7 of this supplier registration form entitled “Location where goods and/or services may be required”, prospective service providers must indicate by means of an X where goods and/or service can be provided based on the location of their entity. Only entities registered with the relevant authorities within the specific province and located in the specific province where the goods or services will be considered for registration onto DoJ & CD supplier database. Prospective suppliers must submit a latest original Utility bill (water and electricity) and a certified copy of its entity business registration in respect to the Province applied for. Failing to comply with this condition will invalidate the prospective supplier’s application.

2. A response to each element set out in section 14, Evaluation matrix (as per page 40)

per element must be prepared and submitted with the application to be considered for registered as a supplier on DoJ & CD supplier database.

(a) Demonstrable experience in similar services undertaken as per principle

business (submit a list of four reference with contactable details, description of goods and/or services rendered, at least four (4) letters of recommendation where goods and/or services were rendered, value of contract awarded)

(b) The prospective service providers or in the case of a joint venture, each

party to the joint venture must submit:

(i) original or certified copies of their entities bank statement for a

consecutive period of any three (3) months for the year 2009 and

2010; and

(ii) Certified copies of the latest Audited Annual Financial Statements,

or

(iii) In the case of a newly established entity, submit the latest Audited

Annual Financial Statement or recent financial results and the bank

statement for a consecutive period of any three (3) months for the

latest financial period Failure to compl y with b (i) and (ii) or (iii ) will automatically invalidates the prospective service providers application.

3. Service providers scoring a total point of 60% or more for functionality will be

placed on DoJ & CD supplier database. Service providers who score less than

60% in respect of functionality will be regarded as having submitted a non

responsive application. Therefore service providers are requested to furnish

detailed information in substantiation of compliance to the requirements of the

evaluation criteria (Section 14).

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4. Government Procurement General Conditions of contract (GCC) as issued by

National Treasury will applicable on all instances. The general conditions is

available on the National Treasury website (www.treasury.gov.za)

5. No advance payment would be made for the procurement of goods or services.

Payment would be made in terms of the deliverables or other unless otherwise

agreed upon by other parties (DoJ & CD and the contractor). DoJ & CD will pay

within the prescribed period according to PFMA. 6. Service providers must complete and submit all relevant information/documentation

required below as insufficient information and non compliance to the conditions set

out will invalidate your application

Fax number

E-mail address

Physical address

Postal address

Tel number (s) as contact number

Cell number (s) as contact number

Location where goods and/or services may be required

Commodity listed ( only five (5) commodity specific as per principle Business. Non compliance to this condition will i nvalidate the prospective suppliers application)

Fill all forms completely

Sign all forms

Preference Points Claim Forms

Valid and original SARS Tax Cle arance Certificate (Failing to submit an original valid Tax clearance certificate will invalidate the prospective suppliers application)

Supplier Maintenance Form

Company / CC Registration Certificate (Issued by CIPRO).

A Business profile of entity of not more than five (5) pages.

All shareholders/ Directors/ Members and in case of one-man concern,

please furnish identity number plus copy of identity documents

3 A list of commodities requirements (page 23 to 27) are enlisted in the supplier

database application form. Prospective suppliers/service providers may apply to be

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enlisted on the supplier database for a maximum of five (5) commodities specific

as per their principle business. Where a prospective supplier has indicated more

than five commodities specific such application would not be considered for

evaluation further.

4 Successful supplier providers enlisted of the DoJ CD supplier database must

submit a new valid current Tax Clearance Certificate to the National Office

(Pretoria) before the validity of the current Certificate expires, in order to ensure

that the Department may continuously consider quotations submitted by your

business.

5 It is imperative that only the DoJ & CD supplier database registration form with

supporting documentation and Original Signatures be submitted. Applications with

copied signatures or any part of the supplier application that has been retyped or

redrafted will not be considered and disqualified for reegistration.

6 Suppliers providing information incorrectly or fraudulently in their Supplier

Database Registration form will be restricted from bidding, in addition to any other

action the Department of Justice and Constitutional Development may institute

against such a supplier. Furthermore, in the event of the DoJ & CD being

prejudiced financially, it reserves the right to take legal action against the supplier

Section 14 14. EVALUATI ON CRITERIA

Functionality will be evaluated on a scale of 0 – 4 in accordance with the criteria

below. The rating will be as follows: 0 = Non Response, 1= Poor, 2 = Average,

3 = Good, 4= Excellent

NO CRITERION: 0 1 2 3 4 WEIGHT SCORE 1 Demonstrable experience in

similar services undertaken ( submit a list of four reference with contactable details)

40

2 Financial stability 30