SMMEs and Historically Disadvantaged Individuals with expertise are particularly encouraged to apply.

APPLICATION FORM TO REGISTER ON THE SERVICE PROVIDER DATABASE

OF THE DEPARTMENT OF RURAL DEVELOPMENT AND LAND REFORM

1

THE FOLLOWING DOCUMENTS/ INFO MUST BE ATTACHED (REQUIREMENTS)

Proof of banking details (Applicants must ensure that the original bank stamp is attached and the bank official must complete the supplier maintenance form/ banking details form, cancelled cheque with original bank stamp attached in the supplier maintenance form will also be accepted).

Confirmation letter from the bank/ Bank statement.

Operating contact and fax numbers.

Company profile with company letterhead must be attached.

Certified copies of ID (shareholders/ members).

CK1.

Valid and original tax clearance certificate.

Proof of registration for any services/ consultancy that requires registration with professional bodies.e.g. CIBD for construction services, PSIRA for security services and etc.

2

SECTION ONE : CONDITIONS

1.1 Please note that all information will be treated confidentially.

1.2 Applications that are incomplete or which are not accompanied by the required documents will be disqualified.

1.3 Completed application forms should be posted to or hand delivered at the above mentioned addresses

1.4 The Department of Rural Development and Land Reforms Service Provider Database will be used mainly for the purposes of identifying entities that can be approached when price quotations for goods and services are to be invited. The fact that an entity is registered as a supplier does not constitute any contractual relationship between that business and the Department of Rural Development and Land Reform.

1.5 For procurement above the financial limit applicable to price quotations, as determined from time to time by National Treasury, the Department Rural Development and Land Reform will normally invite competitive Bids by means of advertisements in the Government Tender Bulletin. The onus is on entities to ensure that they obtain copies of the Bidding documents that are available at the Department of Rural Development and Land Reform when Bids are advertised.

1.6 It is the responsibility of a Registered Entity to inform the Department of Rural Development and Land Reform immediately in writing of any changes in the particulars as stated in the application, especially changes in respect of the HDI equity ownership and the SMME status of the entity. Should a contract be awarded to an entity as a result of incorrect particulars on HDI/SMME status of that entity, the Department of Rural Development and Land Reform shall have the right to, in addition to any other remedy that it may have in terms of the Preferential Procurement Regulations, cancel the contract and to claim damages.

1.7 The Department of Rural Development and Land Reform reserves the right to cancel the registration of an entity if that entity has given incorrect or false information in the application form or any correspondence relating to the application:

Failed to inform the Department Rural Development and Land Reform of any changes of the particulars as furnished in the application

Failed to comply with the conditions of any contract that might have been awarded to the entity

Failed to respond on requests for price quotations

The entity being blacklisted by National Treasury

If the entity has acted in an improper, fraudulent or corrupt manner

3

SECTION TWO : SUPPLIER INFORMATION

2.1 Supplier Details

Registered Name Trading Name Holding Name Company Registration Number Income Tax Registration Number Vat Registration Number Telephone Number Fax Number Cell Phone Number E-Mail Address

2.2 Company Addresses

Postal Address Town Region Code

Physical Address Town Region Code

2.3 Company Type

(Mark with an X in the applicable column)

Public Company Private Company Close Corporation Section 21 Company Trust Partnership Sole Proprietor Parastatal Non Governmental Organisation Other

If selected other, please specify: ________________________________________________________

__________________________________________________________________________________

4

2.4 Contact Person Details

Contact Person Full Name Position in Company Identity Number Telephone Number Fax Number E-Mail Address Telephone Number Cell Phone Number

2.5 Contact Person Addresses

Postal Address Town Region Code

Physical Address Town Region Code

2.6 Supply Region and Town

Please indicate which province you will be capable of delivering goods or services, and indicate the town names within the region. Goods Service Providers must supply proof of satellite office existence should they wish to link themselves to a region where their main offices are not based or attach proof of Goods delivered previously around the area on other projects.

Regions Mark Towns e.g. Region Town A, Town B Eastern Cape Free State Gauteng Limpopo Kwa-Zulu Natal Mpumalanga Northern Cape Western Cape Northwest

5

2.7 Commodities

Please indicate on Annexure A (attached), the goods and/or services, in terms of your Core Business you can offer the Department of Rural Development and Land Reform.

Please note that Service Providers are Limited to Three (3) Commodities

ANNEXURE A

Goods Commodity List

Tick

Agricultural Equipment and Accessories

Agricultural Equipment

Agricultural Accessories

Agricultural Supplies

Live Animals

Animal Feed

Seeds, Bulbs, Seedlings and Cuttings

Fertilizers, Plant Nutrients and Herbicides

Pest Control Products

Air Conditioning, Circulating and Heating Equipment

Air Conditioner

Air Conditioner Regulator

Air Circulating Ventilator

Fans

Heaters

Accommodation Furniture and Furnishings

Reception Chairs and Couches

Benches

Carpet

Blinds and Curtains

6

Accommodation Furnishings

Outdoor Furniture and Furnishings

Tables

Communication Equipment and Accessories

Communication Devices and Accessories

Communication Equipment

Computer Hardware and Software

Computer Monitor

Computer Drives and Writers

Computer Accessories

Printers

Printer Accessories

Printer Toner and Cartridges

Memory Devices

Modems and Motherboard

Network, Port, Hub and Accessories

Software

Licenses

Servers and Accessories

Bags and Cases

Carry Bags

Cases

Luggage and Travelling Bags

Equipment Cases

Cleaning Equipment and Supplies

Cleaning Equipment

Cleaning Supplies

7

Hygiene Supplies

Protective Gear

Uniform

Ladies Blouse Shirts and T-Shirts

Ladies Trousers and Tracksuits

Ladies Dresses and Skirts

Rain Suite

Men Shirts and T-Shirts

Men Trousers and Tracksuits

Jerseys and Sweater

Jackets and Blazers

Socks, Scarf and Belts

Footwear

Protective Apparel

Groceries

Beverages

Bread and Bakery products

Groceries and Vegetables

Kitchen and Electrical Appliances and Supplies

Kitchen Appliances

Crockery and Cutlery

Kitchen Supplies

Office Machines and Equipment and Supplies

Office Machine

Office Equipment

Office Supplies

Optical and Navigational Equipment

8

Optical Equipment

Navigation Equipment

Medical Equipment and Supplies

Medical Equipment

Medical Supplies

Office Furniture and Furnishings

Desks

Chairs

Credenzas

Cupboard and Bookcase

Drawers

Cabinets and Filing Cabinet

Bulk Filing Unit

Steel Factory Lockers

Boardroom Tables

Office Furnishings

Tables and Counter Tops

Wall Units

Photographic, Printing and Presentation Equipment and Supplies

Printing and Publishing Equipment

Audio and Visual Presentation and Composing Equipment

Photographic or Filming or Video Equipment

Photographic and Recording Media

Photographic Filmmaking Supplies

Promotional Items and Gifts

Corporate Gifts

Promotional Items

9

Displays and Stands

Published Products

Printed Media

Electronic Reference Material

Signage and Accessories

Property, Land and Temporary Shelter

Prefab House

Mobile House

Shelter

Land

Fixed Property

Recreational and Sporting Equipment and Accessories

Sports Equipment and Accessories

Sports Kit

Safety and Security Equipment and Accessories

Safety Equipment

Security Accessories

Alarm and Security Systems

Locks and Handles

Stationery

Book, Pads and Legal

Boards and Flip Charts

Boards and Flip Charts Consumables

Correction Fluids and Tape

Desktop Stationery

Envelopes and Packaging

Filing and Storage

10

File Dividers and Indexes

Glue, Labels and Tapes

Markers and Highlighters

Paper and Board

Pens and Refills

Pencil, Clutch and Refills

Punches and Staplers

Staples and Staple Remover

Stamps

Stamp Pad and Ink

Graphic and Technical Drawing

Tools and General Equipment

Hand Tools

Electrical Tools

General Equipment

Garden Equipment

Maintenance Supplies and Accessories

Electrical Supplies

Plumbing Supplies

General Maintenance Supplies and Accessories

Surveying and Measuring Tools

Surveying Tools

Measuring Tools

11

Services Commodity List

Auctioneer Services

Live Stock Auction

Vehicle Auction

Property Auction

Furniture Auction

House Auction

Agricultural Support

Participatory Situation Analysis

Land Resource Assessment / Feasibility Study

Farm Management Development and Support

Farm Management Planning

Agricultural Economic Support

Agricultural Extension and Training Support

Agricultural Engineering Support

Training in Extension Services for Farming

Agricultural Advisory Services

Cleaning Services (Certification Required)

General Building Cleaning Services Interior

General Building Cleaning Services Exterior

Hygiene Services

Carpet Cleaning Services

Garden and Plant Maintenance Services

Vehicle Cleaning Services

Waste Management Services

Community Support / Project Support

Legal Entity Establishment

12

Mediation and Conflict Resolution

Land Reform Project Facilitation, Community Surveying and Scoping (RLCC)

Beneficiary Verification

Institutional Development and Capacitation

Project Management

Construction Services (CIDB Certification Required)

Structural VIP Toilets, Houses

Building Including Material

Civil Roads, Bridges

Mechanical - Engineers

Fencing Including Material and Installation

Structural Renovation

Equipment Hire

Catering Equipment

Construction Equipment

Earthmoving Equipment

General Equipment

Tents and Marques

Education and Training Services (Certification Required)

Professional Training

Alternative Educational Systems

Educational Institutions

Specialized Educational Services

General Building Maintenance and Repair Services (Certification Required)

Locksmith Services

Partitioning Services

13

Window Services

Fumigation Services

Pest Control Services

Electrical Services

Plumbing Services

Health Services

Wellness Services

Interior Decorating and Household Services

Dry Cleaning and Laundry Services

Upholstery Services

Floor Ware Installation Services

Interior Decorating Services

Installation Services of Curtains and Blinds

Wall Ware Services

Information Technology Services

Installation Services

Specialized IT Services

Hardware Repairs and Maintenance Services

Data Management and Backup Services

Upgrades and Maintenance

G.I.S System Design

Database Development and Design

Land Tenure Specialists

Rights Enquiries

Act Commissioners

Lease of Equipment and Machine

Beverage Vending Machine

14

Photocopy Machine

Water Coolers

Logistical Services

Catering Services

Exhibition Centre and Meeting Facilities

Event Management Services

Management and Business Professionals and Administrative Services (Certification Required)

Management Advisory Services

Subscriptions Services

Real Estate Services

Marketing and Distribution Services

Policy Development and Management Services

Document and Information Management Services

Business Administration Services

Monitoring and Evaluation

Land Reform Programme Management M&E

Project Monitoring and Evaluation

Organisational Monitoring and Evaluation

Diagnostic Evaluation Studies

Human Resources Services

Human Resources Development Services

Human Resources Management Services

Legal Services (Certification Required)

Conveyancing

Notaries / Notary Public

15

Land Legal Specialist

Land Reform Law Specialist

Land Reform Mediator

Business Plan

Business Plan (RLCC)

Business Plan (PLRO)

Auditing Services (Certification Required)

Financial Services (Certification Required)

Business and Financial Advisory Services

Finance Systems Designing Services

Charted Accounts Services

Valuations

Agricultural / Rural

Urban and Commercial / Industrial

Property Assessors

Land Management Support

Farm / Property Management On-Site

Lease Management

State Land Issues

Audit on State Land

Land Use Investigation

Land Reform Services

Land Development Planning Services

16

Land Reform, Restitution, Redistribution and Land Tenure Programme Services

Agricultural Support and Technical Project Support Services

Institutional and Social Development Services - LR Programme

Land Surveying (Certification Required)

Land Surveyors

Publications, Communication and Information Services

Advertising on newspapers

Publications

Writing and Translations Services

Printing and Reproduction Services

Photographic Services

Graphic Design Services

Panel Services

Project Panel

Regional and Integrated Rural Development Planning

Regional and Integrated Rural Development Planning

Township Establishment

Engineering Support

Environmental Impact Assessment / Environmental Scoping

Land Use Planning (RLCC)

Relocation, Removals and Storage, Transportation and Mail Services

Mail and Cargo Transport

Bus and Public Transport

Office Furniture and Household Relocation, Removal and Storage

Distribution and Delivery Services

Chauffer and Shuttle Services

Transportation or Moving of Livestock Services

17

Security and Safety Services (Certification Required)

Security and Personal Safety

Security Surveying Services

Telecommunication Services

Telecommunication Installation

Telecommunication Maintenance and Repairs

Services and Repairs

Service and Repairs of Office Machine

Service and Repairs of Furniture

Service and Repairs of Equipment

Water Provision (Certification Required)

Water Provision Contractors / Consultants

Borehole Construction

NB: Entities are free to supply details of any other products or services they render which are not included on the above lists.

..

..

..

..

..

..

..

18

2.8 References

Please list contracts/assignments completed by your company in the last three (3) years in relation to the commodities you linked your company to.

Work Performed Client Contact Person and Telephone Number

19

SECTION THREE : HDI AND SMME DECLARATION

3.1 Equity Ownership

Please indicate in %, shares owned by the following groups: (Compulsory)

Group Male Female Disabled Black Coloured Indian White

3.2 BEE

Please indicate the Management structure in % of the total percentage owned.

Group Percentage Owned African Coloured Indian

3.3 HDI Ownership

Historically Disadvantaged Individuals (HDI) Women Equity (WE) Disabled Individuals (DI)

3.4 BBBEE

Has your company been assessed for BBBEE? (Yes/No) Which assessment company has provided your company with your BBBEE rating?

What is your BBBEE rating? Please attach copy of Certificate (Is Certificate attached?)

3.5 SMME Status

(Mark with an X in the applicable column)

Micro Small Medium Large

20

3.6 Declaration

I/We the undersigned declare that:

1. The information furnished is true and correct 2. The Equity Ownership claimed is in accordance with the General Conditions

___________________________ _________________________

Signature of Owner or Authorised Date

Representative

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SECTION FOUR : OFFICE LIST FOR DATABASE DEVELOPMENT

4.1

OFFICE PHYSICAL ADDRESS CONTACT NUMBERS 1 PSSC: KwaZulu Natal 270 Jabu Ndlovu Street,

Pietermaritzberg 033 264 9500/6546

2 PSSC: Eastern Cape Block H, Ocean Terrace Quigney, East London

043 743 0078

3 PSSC: Western Cape Van der sterr Bulding, Rhodes Avenue, Mowbray

021 658 4300/4482

4 PSSC: Free State SA Eagle Building,136 Maitland Street, Bloemfontein

051 447 8465/ 6140

5 PSSC: Northern Cape Corner Knight and Stead Street 6th Floor New Public Building, Kimberley

053 830 4000/4041

6 Mpumalanga Provincial Land Reform Office

Home Affairs Building 4th Floor Cnr Henshall & Andrew Street, Nelspruit

013 755 3499

7 Mpumalanga Regional Land Claims Commission

30 Samora Machel Drive, Restitution House, Nelpruit 1200

013 756 6093/6088

8 Limpopo Provincial Land Reform Office

Andria Building, Second floor, Cnr Schoeman and Rissik Street, Polokwane

015 297 3539

11 Limpopo Regional Land Claims Commission

Kagiso House, Cnr Schoeman & Rissik Street, Polokwane

015 284 6300

12 PSSC: North West Shama Investment Building 9 Shippard, Mafikeng

018 397 9700

13 North West Regional Land Claims Commission

ABSA Building, Ground Floor, Cnr Provident & University Drive, Mmabatho

018 389 9600/9620

14 PSSC: Gauteng 1145 Burnett Street, Hatfield, Pretoria 0025

012 432 4200

15 Gauteng Regional Land Claims Commission

9 Bailey Lane, Arcadia, Pretoria 012 310 6500/6526

16 Head Office 184 Jacob Mare Street, Old Building, Room 14D, Pretoria

012 312 9786/9863