SUPPLIER REGISTRATION FORM

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SUPPLIER REGISTRATION FORM For Enquiries Contact: Samuel Thobela Procurement TEL: (013) 752 6839 FAX: (013) 755

1 SUPPLIER REGISTRATION FORM For Enquiries Contact: Samuel Thobela Procurement TEL: (013) FAX: (013) NEL STREET P.O. BOX NELSPRUIT NELSPRUIT Page 1 of 20

2 TOWN MANAGER MOTIVATION FOR NEW VENDOR Date Received: Date Processed: APPLICATION CAPTURED BY Signature: Date: APPLICATION CONFIRMED BY: Signature: Surname & Initials: INTRODUCTION Sembcorp Silulumanzi hereby invites current and prospective suppliers to apply to be verified and registered on the Company Supplier Database. Henceforth, Sembcorp Silulumanzi will not do business with suppliers that are not validated and registered on the database with a valid vendor number. Suppliers currently doing business with Sembcorp Silulumanzi must reapply in terms of this new process. Instructions to Suppliers: 1. The application forms must be completed in full. 2. All the required and supporting documentations must be submitted jointly with the form. Company profiles and brochures are also welcome. Page 2 of 20

3 3. Failure to submit supporting and requested information will lead to your company being registered, but not available to be used by Sembcorp Silulumanzi. 4. The Required Information section on page 4 is an indication of what information is required for your business to be verified and registered without delays. 5. The Checklist for Sembcorp Silulumanzi Officials section on page 5 is not to be completed by Suppliers. 6. Business Registration and Business Information sections on pages 6 to 9 are pre-requisites for registration and therefore must be completed in full. Failure to complete this section will lead to your business not being registered. 7. It is compulsory to complete Products and/or Services section on page 9.Please tick in the appropriate box. This section will enable Sembcorp Silulumanzi to grant your company an opportunity to submit quotations or tenders whenever the opportunities arise. Sembcorp Silulumanzi will still invite tenders through public media. Failure to provide Products and/or Services indicated by your company will result in immediate removal from the database. 8. Trade Experience section on page 9 must be completed in full to give Sembcorp Silulumanzi an understanding of whether your firm has experience of supplying the products and services your firm is applying for. Lack of experience will not necessarily lead to your firm not being verified or registered. 9. Latest audit financial statements must be supplied with the application to give Sembcorp Silulumanzi an understanding of your company s financial standing. Start up companies without financial history will also be eligible for registration. 10. Facilities, Plant and Equipment section on page 11 must be completed in full to give the city an indication of your technical capacity. 11. Declaration by business under oath on page 14 is compulsory and must be completed in full by all suppliers. Failure to comply with the requirement will lead to your company not being registered. 12. Sembcorp Silulumanzi reserves the right to validate all information supplied and any misrepresentation of facts may lead to disqualification and potentially being restricted to do business with Sembcorp Silulumanzi in future. 13. A duly completed form together with supporting documentation must be submitted to the address indicated on the front page. 14. For assistance on how to complete the form or any other query related to this process please contact Samuel Thobela on (013) Sembcorp Silulumanzi will inform suppliers of the status of their application in writing / / sms / fax. REQUIRED DOCUMENTS Documents Required Page 3 of 20 Sole Proprietor Business Corporations Close Type Partnerships Company Public / Private Business Trust Non Profit Organisation Institutions

4 1. Company Registration (Certified Copies 2. Latest Rates and Taxes Statement or lease agreement (Municipal/ Silulumanzi Account) 3. Original Tax Clearance Certificate 4. Proof of Registration to a Statutory Body Regulating your Industry 5. Certified Copy of ID 6. Skills Development 7. Audited Financial Statement 8. Broad-Based Black Economic Empowerment Compliance N/A Supply Latest Certified Copy For the owner of the business Certificate of CK1 / CK2 incorporation Supply Latest Certified Copy For the company Duly Signed Partnership agreement Supply Latest Certified Copy For the partnership Certificate of Incorporation CM2C & Auditors Confirmation Letter Supply Latest Certified Copy For the company Deed of Trust Agreement Supply Latest Certified Copy Certificate of Incorporation Section 21 Supply Latest Certified Copy For the trust For the NPO / Proof of Exemption Registrar of Close Corporation & Companies Local Authority Receiver of Revenue (SARS) If applicable If applicable If applicable If applicable If applicable If applicable Industry Regulatory Authority Clear copy of Identity Document of owner Latest Proof of Payment Latest Statement (If Applicable) Valid BEE Certificate Clear copy of Identity Document of members Latest Proof of Payment Latest Statement (If Applicable) Valid BEE Certificate Clear copy of Identity Document of partners Latest Proof of Payment Latest Statement (If Applicable) Valid BEE Certificate N/A Latest Proof of Payment Latest Statement (If Applicable) Valid BEE Certificate Clear copy of Identity Document of trustees Latest Proof of Payment Latest Statement (If Applicable) Valid BEE Certificate Clear copy of Identity Document Latest Proof of Payment Latest Statement (If Applicable) Valid BEE Certificate Page 4 of 20

5 DOCUMENTS TO BE ATTACHED Y N NA 1. Company Registration Document 2. Proof of Ownership 3. Latest Rates and Taxes Statement 4. ORIGINAL Proof of Banking (Letter from the Bank or Cancelled cheque) 5. ORIGINAL Tax Clearance Certificate 6. Proof of Registration to a Professional Body Regulating your Industry 7. Certified Copy (ID) 8. Company Profile 9. Valid BEE Certificate Page 5 of 20

6 1. COMPULSORY REQUIREMENTS BUSINESS REGISTRATION DETAILS NB: Documentary proof must be provided as in page 1 (please mark relevant box) 1.1 TYPE OF BUSINESS ENTITY PUBLIC COMPANY LTD PRIVATE COMPANY (PTY) LTD CLOSE CORPORATION CC SOLE PROPRIETOR PARTNERSHIP BUSINESS TRUST Certified of Incorporation CM2 & Auditors Confirmation Letter Certificate of Incorporation CM2 & Auditors Confirmation Letter Certificate of incorporation CK1 / CL2 Copy of ID (Certified) Duly Signed Partnership Agreement Deed of Trust Agreement NON PROFIT ORGANISATION Certified of Incorporation Section BUSINESS / COMPANY REGISTRATION NUMBER If Sole Proprietor ID Number Have you attached proof of registration documents? 1.3 VAT REGISTRATION NUMBER Y N If you qualify for VAT exemption, please attach a VAT exemption document Not applicable to all business. Have you attached proof of your VAT 103 Registration documents? Y N 1.4 PROOF OF P.A.Y.E. DOCUMENT Not applicable to all companies. Please specify if N/A Have you attached proof of P.A.Y.E. documents? Y N N/A 1.5 INCOME TAX REGISTRATION Income Tax Registration Number If qualify for Income Tax exemption, please attach an Income Tax exemption approval letter Not applicable to all companies. Please specify if N/A Have you attached proof of your Income Tax documents? Y N N/A Page 6 of 20

7 1.6 TAX CLEARANCE CERTIFICATE Original of a valid Tax Clearance Certificate must be supplied (Less than 6 months) Have you attached proof of tax clearance? Tax Clearance Certificate Number: Y N Tax Clearance Certificate Expiry date: 1.7 MUNICIPAL RATES AND TAXES ACCOUNT Municipal Account Number or Silulumanzi Account number Attach latest statement Name of local municipality Have you attached latest Municipal statement? Y N 1.8 PROOF OF REGISTRATION TO/ACCREDITATION BY A STATUTORY BODY REGULATING YOUR INDUSTRY Registration Number Not applicable to all companies. Please specify if N/A Have you attached proof of your registration/accreditation documents? Y N N/A 1.9 Do you give Settlement Discount if payment is made within 30 days? If YES indicate % Y N % 2. BUSINESS INFORMATION 2.1 REGISTERED BUSINESS NAME 2.2 TRADING NAME 2.3 REGISTERED BUSINESS ADDRESS CITY Page 7 of 20

8 PROVINCE CODE 2.4 PHYSICAL ADDRESS (If different from 2.3) CITY PROVINCE CODE 2.5 POSTAL ADDRESS CITY PROVINCE CODE SPECIFY THE WARD NUMBER WHERE BUSINESS WILL BE CONDUCTED FROM 2.6 TELEPHONE NUMBER MOBILE NUMBER FAX NUMBER ADDRESS 2.7 DETAILS OF CONTACT PERSON TITLE Page 8 of 20

9 NAME SURNAME DESIGNATION TELEPHONE NUMBER MOBILE NUMBER FAX NUMBER ADDRESS REFERRED METHOD OF CORRESPONDENCE Fax Telephone 2.8 BUSINESS WEB-PAGE ADDRESS 2.9 SUPPLIER CLASSIFICATION: (Please the relevant box or boxes) Original Equipment Manufacturer (OEM) Manufacturer Distributor/ Supplier/Agent Professional Service Provider 2.10 LIST OF SERVICE PROVIDERS PROVIDING THE FOLLOWING SERVICES: SERVICE BUSINESS NAME ADDRESS CONTACT PERSON TELEPHONE Legal Banking Insurance Accounting Page 9 of 20

10 3. PRODUCTS AND SERVICES 3.1 LIST OF PRODUCTS AND SERVICES Please indicate the nature of operations, products or services applicable to your business. COMMODITY 1 AGRICULTURAL SUPPLI ES 2 AIR PURIFYING EQUIPMENT 3 ALARM AND SECURITY SYSTEM 4 BEVERAGES 5 BOLTS & NUTS 6 BUILDING MATERIAL 7 CHEMICALS 8 CLEANING EQUIP AND SUPPLIES 9 CLOTHING 10 COMMUNICATION EQUIPMENT AND ACCESSORIES 11 COMPUTER EQUIPMENT & SOFTWARE 12 CONTAINERS AND PACKAGING SUPPLIES 13 ELECTRONIC COMPONENTS 14 ELECTRICAL COMPONENTS (INCLUDING TRANSFORMERS) 15 ELECTRIC INSULATION & WIRES & BRUSHES (INCL.CABLE) 16 ELECTRICAL SWITCHGEAR 17 MINI SUBSTATION 18 FIBRE OPTIC 19 FILTER 20 FIRE,RESCUE & SAFETY EQUIP Page 10 of 20

11 21 FIREARMS, AMMUNITION AND ACCESSORIES 22 FUEL AND LUBRICANTS 23 FURNITURE 24 GARDENING EQUIPMENT AND ACCESSORIES 25 GENERAL HARDWARE 26 GIFTS 27 GROCERIES 28 HIRE 29 KITCHEN & FOOD APPLIANCES 30 LABOUR SAVING DEVICES AND ACCESSORIES 31 LIBRARY SERVICES 32 MEDICAL 33 MEDICAL EQUIPMENT 34 NUTRITIONAL CARE 35 PAINT SEALER ADHESIVE AND ACCESSORIES 36 PHOTOGRAPHIC EQUIPMENT 37 REFRIDGERAT'ON,AIR CONS,AIR CIRCULATION 38 PRECAST CONCRETE 39 SCAFFOLDING AND LADDERS 40 SIGNS AND ACCESSORI ES 41 SOUND RECORDING EQUIPMENT AND ACCESORIES 42 STATIONERY 43 STEEL: BAR, WIRE, MESH 44 TAR PRODUCTS Page 11 of 20

12 45 TOILETRIES 46 TOOLS, HAND AND MACHINE (ALL) 48 PUMPS & VALVES 49 WASTE DISPOSAL 50 WATER AND SEWER 51 WATER PURIFICATION 52 AGRICULTURAL SUPPORT SERV 53 CLEANING SERVICES 54 COMMUNICATION & INFORMATION MANAGEMENT SUPPORT SERVICES 55 FINANCIAL SERVICES 56 GENERAL SERVICES 57 HR MANAGE SUPPORT & SERV 58 INFORMATION TECHNOLOGY SERVICES 59 INSTALLATIONS, MAINTENANCE & REPAIR SERVICES 60 INTERIOR DECORATING AND HOUSEHOLD SERVICES 61 LAND DEVELOPMENT PLANNING SERVICES 62 LAND REFORM, RESTITUTION, REDISTRIBUTION PROGRAMME SERVICES 63 LEGAL SERVICES 64 LOGISTICAL SERVICES 65 REPROGRAPHIC SERVICES 66 SOCIAL SERVICES LAND TENURE 67 SHE: SAFETY (SECURITY), HEALTH & ENVIRONMENT SERVICES 68 SIGNAGE & ENGRAVING SERVICES Page 12 of 20

13 69 TELECOMMUNICATION SERVICES 70 TRAINING OF STAFF & COMMUNITY TRAINING SERVICES 71 TRANSPORT, RE-LOCATION & FREIGHT SERVICES 72 VALUATION SERVICES 73 VEHICLE MAINTENANCE & SERVICES 74 PROFESSIONAL SERVICES (INCLUDING CONSULTANTS) 75 MOTORISED PLANT SPARES 76 MOTORISED VEHICLES 77 SANITARY WARE 78 RAIN WATER GOODS 79 MOBILE CONTAINER HOME AND OFFICES 80 WELDING RELATED EQUIP 81 ENGINEERING SERVICES 82 PUBLISHERS & SUPPLIERS OF BOOKS 83 CATERING 84 LABORATORY & ENVIRONMENT EQUIP 85 FLEET MANAGEMENT Page 13 of 20

14 4. TRADE EXPERIENCE 4.1 Do you have any previous contract work or tendering experience? Y N If yes, please complete the fields below. List the last contracts awarded to you (the or previous experience with other business related to this type of work supply. A. TENDERS tendering business) 1. Name 3 tender references / referees of previous projects and provide their name(s) and telephone numbers. Business Name Contact Number Contact Person Number of years Address Value of Business (Rands) B. COMMERCIAL 1. Name 3 commercial references / referees of previous projects and provide their name(s) and telephone numbers. Business Name Contact Number Contact Person Number of years Address Value of Business (Rands) 5. LEGAL INFORMATION 5.1 Are there any pending legal proceedings or previous judgements against your business or has your business ever been Y N declared bankrupt. If yes, please elaborate: 6. DECLARATION OF ANY CONFLICT OF INTEREST 6.1 Are you currently working as an employee in Sembcorp Silulumanzi and/or related company? Yes No 14

15 If Yes, give details: 6.2 Have you worked in Sembcorp Silulumanzi and/or related company * for the past 12 months? Yes No If Yes, give details: 6.3 Do you have any relative working for Sembcorp Silulumanzi and/or related company? Yes No If Yes, give details: 6.4 Do you have any close relationship with any official working in our establishment (except for the above)? Yes No If Yes, give details: 6.5 Is there any other relevant information that you would like to disclose? Yes No If Yes, give details: 7. QUALITY, SAFETY AND ENVIRONMENT A. TECHNICAL 1. Is your business a permit holder under the SABS marks scheme or ISO? If Yes, indicate products for which permits are held, including permit Y N numbers. Product Name Permit Number Product Name Permit Number Product Name 15

16 Permit Number Product Name Permit Number B. ENVIRONMENTAL 1. Do you have an Environmental Policy in place? Y N N/A 2. Does your facility routinely work with any hazardous substances? Y N 1. Please give a summary of your plant and / or facilities: (Photos are welcome) C. FACILITIES, PLANTS AND EQUIPMENT 2. Describe all property agreements relating to facilities used by the firm and the nature of the agreement indicating whether facilities are owned or leased by the firm: Facility Owned / Rented Rental Amount/Month Owner Agreement Type 3. Number of Employees Full Time Part Time (Maximum of 5 will be registered) Trade names (Example: iqual) 8. TRADE NAMES Description (Example: Sole supplier of iqual Database Software) 16

17 9. BBBEE/BEE STATUS (Tick/Select Applicable Box) Select Your Business BEE Component/Ownership: BO (Black Owned, 50% + 1 vote) BE (Black Empowered, 25,1% - 50%) BI (Black Influenced, 5,1% - 25%) ES (Empowering Supplier, 1% - 5%) WO (White Owned, 0%) Has Your Business Undergone A Formal Broad Based Black Economic Empowerment (BBBEE) Accreditation? (Tick/Select Applicable Box) Yes No If Answered "Yes", State The Name Of The Accreditation Agency: Indicate Your BBBEE Level Of Accreditation: (Tick/Select Applicable Box) Level 1 (100 Points Scored Or More) Level 2 (85 To 100 Points Scored) Level 3 (75 To 85 Points Scored) Level 4 (65 To 75 Points Scored) Level 5 (55 To 65 Points Scored) Level 6 (45 To 55 Points Scored) Level 7 (40 T0 45 Points Scored) Level 8 (30 To 40 Points Scored) Non Compliant (Less Than 30 Points Scored) BBBEE Certificate Expiry Date: OWNERSHIP: (compulsory - Failure to complete this section will result in the application being declined) HDI OWNERSHIP STATUS: 17

18 (Summary) Percentage Persons/Entities Owners who are Historically Disadvantaged Individuals (HDI) Percentage Persons/Entities Owners who are % % Women Equity (WE) Percentage Persons/Entities Owners who are % Disabled Individuals (DA) Please complete the following information on the next page: 18

19 CREDIT ORDER INSTRUCTION FORM ATTENTION: I/We hereby request and authorise you to pay any amounts which accrue to me/us to the credit of my /our bank account with the mentioned bank. I/We understand that the credit transfer hereby authorized will be processed by computer through a system known as the "ACB ELECTRONIC FUNDS TRANSFER SERVICE", and I/we also understand that no additional advice of payment will be provided by my/our bank. Initials and surname Authorised signature Date Name of individual/organisation: Name of bank: Branch code: Account number: *Type of account: 1 - Cheque account 4 - Bond account 2 - Savings account 5 - (Not in use) 3 - Transmission account 6 - Subscription Share account PLEASE ATTACH ORIGINAL PROOF OF BANK DETAILS 19

20 DECLARATION BY BUSINESS UNDER OATH I / We. declare that the above particulars and information furnished to Sembcorp Silulumanzi for the purposes of registering our organization on the supplier database are true in substance and in fact and that I / We fully understand the meaning thereof. Name: Signature:. Date:.. Designation: 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 OATHS NOTE: SUPPLIERS PROVIDING FALSE OF FRAUDULANT INFORMATION OR DOCUMENTATION SHALL SUBJECT THEMSELVES TO IMMEDIATE DISQUALIFICATION. 20

Supplier Registration Application Form

Supplier Registration Application Form For Enquiries contact: Tumelo Mosia Financial Risk and Procurement Tel: 012 345 1046 The forms must be submitted at: Basia Consulting (Pty) Ltd 90 Sovereign Drive