SUPPLIER DATABASE REGISTRATION NAME OF SERVICE PROVIDER: _________________________________ (To be completed by supplier) FOR OFFICIAL PURPOSES Verified By: Verified by: ________________ Persal No: ______________ Signature: ________________ Date: ______________ Captured By: Captured by: ________________ Persal No: ______________ Signature: ________________ Date: ______________ Entity Maintenance No: Captured by: ________________ Persal No: ______________ Signature: ________________ Date: ______________ APPLICATION ACCEPTED APPLICATION REJECTED DoJ & CD Supplier Number 2 of 26 SUPPLIER DATABASE REGISTRATION The Department of Justice and Constitutional Development (DoJ&CD) is an outwardly focused, customer-centred 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 DoJ&CD Supply Chain Management Policy invites service providers to register on DoJ&CD’s database of suppliers/services as official vendors and suppliers for the 2012 to 2013 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. 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 J. Mokgothu 012 315 1682 jmokgothu@justice.gov.za 086 641 3835 B. Mokhutle 012 315 1546 bmokhutle@justice.gov.za 086 678 2168 K. Masilo 012 357 8198 kmasilo@justice.gov.za 086 642 3759 Completed registration forms must 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). Closing date: 30 November 2012 at 11:00 3 of 26 Information Checklist Submitted Yes No Telephone / Cell number as contact Physical address and Postal address Fax number or E-mail address Valid and Original SARS Tax Clearance Certificate Original or certified copy of B-BBEE certificate Original latest Bank Statement or Bank Letter with a bank stamp Company / CC Registration Certificate (Issued by CIPRO). Certified copy of identity documents (ID) of all shareholders/members/Directors or sole traders Latest entity’s original or certified water /electricity Utility bill A Business profile of not more than five (5) pages Commodity listed only five (5) may be selected Location where goods and/or services may be required Fill all forms completely Sign all forms 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 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 database; Only successful suppliers will be notified in writing on their application been accepted; 4 of 26 1. SUPPLIER DETAILS (All fields are mandatory) Company Details: Legal Name: Trading Name: Registration Number: VAT Number: Income Tax Number: Company Contacts: Telephone Number: Fax Number: E-mail Address: Website Address Postal Address: Physical Address: Main contact: Name: Surname: Position: Telephone Number: Facsimile Number: Cellular Number: E-mail Address: 5 of 26 2. SUPPLIER GROUPING DETAILS: (Please mark with an X the relevant box) 1. Public Company (LTD) 7. Foreign Company 2. Private Company (PTY) LTD 8. Joint Venture / Consortium 3. Closed Corporation (CC) 9. Section 21 Company 4. Sole Proprietor 10. Government / Parastatals 5. Partnership 11. Co-operative 6. Trust 11. Other (Please specify) 3. BROAD-BASED BLACK ECONOMIC EMPOWERMENT (B-BBEE) VENDOR PROFILE List all partners / owners and shareholders (Compulsory) Name and Surname Position Citizenship ID Number Note: Where owners are themselves a company or partners, owners of the holding firm must be identified. Certified ID copies of partners, members, shareholders or owners must be attached. BROAD-BASED BLACK ECONOMIC EMPOWERMENT (B-BBEE) INFORMATION Please mark your B-BBEE credentials with an (X) B-BBEE Status B-BBEE Recognition Level % Mark with an (X) Level 1 Contributor 135% Level 2 Contributor 125% Level 3 Contributor 110% Level 4 Contributor 100% Level 5 Contributor 80% Level 6 Contributor 60% Level 7 Contributor 50% Level 8 Contributor 10% Non-Compliant Contributor 0% Exempted Micro-Enterprise(EME) Any enterprise with an annual total Revenue of R5 million or less qualifies as an Exempted Micro- Enterprise (EME). A start-up enterprise must be measured as an Exempted Micro-Enterprise for the first year following its formation or incorporation. I/ We confirm that the information provided is correct as at this date: Name and Surname Signature Position Date 6 of 26 4. DECLARATION Verification of information supplied in this document, including attached documents: I/We, the undersigned, warrant 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 cannot 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, Identity Documents and other copies. Verification of information supplied will perform against third party source such as SARS, CIPRO or CIPC, Safety net, etc. Please notify the Department immediately of any change to the provided information. Please ensure all fields are completed. Incomplete application forms will not be processed. Supplier Name: ____________________________________________________________ ________________________________________ __________________________ Signature of Authorised Representative Signatory Name in Print ________________________________________ __________________________ Signatory Position: Signatory ID Number: Signed at __________________________ on this ____ day of________________ 20_____ 7 of 26 6. SUPPLIER MAINTENANCE FORM: BAS JYP PERSAL PLEASE WRITE IN BLOCK LETTERS I/We hereby request and authorize 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 authorized 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: Authorized By: Date Authorized: Supplier code: SUPPLIER NO 8 of 26 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 9 of 26 *Please include CC/CK where applicable 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 10 of 26 6. LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY. FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PROSPECTIVE SUPPLIERS APPLICATION. Eastern Cape Location Mark with X Location Mark with X Aberdeen Matatiele Adelaide Mdantsane Albany Middelburg Albert Middledrift Alexandria Molteno Aliwal North Mount Ayliff Barkly East Mount Fletcher Bathurst Mount Frere Bedford Mpofu (Stockenström) Bizana Mqanduli Butterworth Ngqeleni Cathcart Nqamakwe Cradock Ntabathemba East London Pearston Elliot Peddie Elliotdale Port Elizabeth Engcobo Port St Johns (Umzimvubu) Flagstaff Queenstown Fort Beaufort Qumbu Glen Grey Somerset East Graaff-Reinet St Marks Hankey Sterkstroom Herschel Steynsburg Hewu Steytlerville Hofmeyr Stutterheim Humansdorp Tabankulu Idutywa Tarka Indwe Tsolo Jansenville Tsomo Joubertina Uitenhage Keiskammahoek Umtata Kentani Umzimkulu King William’s Town Venterstad Kirkwood Victoria East Komga Willowmore Lady Grey Willowvale (Gatyana) Libode Wodehouse Lusikisiki Xalanga (Cala) Maclear Zwelitsha [...]... any part of the supplier application that has been retyped or redrafted will not be considered and disqualified for re -registration 7 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,... application 5 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 6 It is imperative that only the DoJ & CD supplier database registration form... 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 Prospective suppliers must submit a latest original Utility bill (water and electricity) and a certified copy of its entity business registration in respect... the Company (director, trustee, shareholder², member): ………………………………………………………………………………………………………… 2.4 Registration number of company, enterprise, close corporation, partnership agreement or trust: ……………………………………………………………………… ………….…………………… 2.5 Tax Reference Number: ………………………………………………………………………… 2.6 VAT Registration Number: ………………………………… ……………………………… 2.6.1 The names of all directors / trustees / shareholders... PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PROSPECTIVE SUPPLIERS APPLICATION Northern Cape Location Mark with X Barkly West Britstown Calvinia Carnarvon Colesberg De Aar Douglas (Herbert) Fraserburg Galeshewe Garies Griekwastad (Hay) Groblershoop Hanover Hartswater... PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PROSPECTIVE SUPPLIERS APPLICATION Western Cape Location Albertinia Atlantis Beaufort West Bellville Bonnievale Bredasdorp Caledon Calitzdorp Cape Town Ceres Clanwilliam George Goodwood Grabouw Heidelberg Hermanus... PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PROSPECTIVE SUPPLIERS APPLICATION Free State Location Mark with X Location Bethlehem Marquard Bethulie Bloemfontein Boshof Bothaville Botshabelo Brandfort Bultfontein Clocolan Memel Odendaalsrus Parys Paul Roux Petrusburg... PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PROSPECTIVE SUPPLIERS APPLICATION Gauteng Location Mark with X Location Mark with X Alberton Benoni Daveyton Boksburg Brakpan Bronkhorstspruit Cullinan Germiston Heidelberg Johannesburg Regional Office Kempton Park... 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 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... PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS AND SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY FAILING TO COMPLY WITH THIS CONDITION WILL INVALIDATE THE PROSPECTIVE SUPPLIERS APPLICATION Kwazulu Natal Location Babanango Bergville Camperdown Chatsworth Colenso Dannhauser Dukuza Dundee Durban Emlazi Ekuvukeni Empangeni Emzumbe Enseleni Eshowe Estcourt Emnabithi Glencoe . vendor /supplier database. 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. DoJ&CD’s database of suppliers/services as official vendors and suppliers for the 2012 to 2013 Financial Year. Suppliers and service providers currently registered as vendors on the DoJ&CD database. 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;