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

SECTION ONE : MANDATORY DOCUMENTS

1.1 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).

1.2 Bank statement

1.3 Entity Maintenance form must be in an original form and fully signed. (Copies will not be excepted)

1.4 Company profile clearly indication core business (Service provider must indicate their core business in order of preference).

1.5 Certified copies of ID (shareholders/ members).

1.6 CK1

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

1.8 Operating contact and fax numbers.

1.9 Valid and original tax clearance certificate: verification proof of TCC from SARS.

1.10 A fully completed application form and signed

NB: Failure to submit all of the above information will result in disqualification.

It is recommended that Departments add the following declaration to their Supplier Registration Forms for the Supplier to sign:

For purposes of section 256 of the Tax Administration Act of 2011 (the TAAct), the contractor / service provider authorizes the South African Revenue Service to disclose ‘taxpayer information’ as contemplated under the provisions of Chapter 6 of the TAAct in relation to the compliance status of tax registration, tax debt and filing requirements of

________________ _______________ _____________

Name of other party here Signature Date

2

SECTION TWO : CONDITIONS

2.1 Please note that all information will be treated confidentially.

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

2.3 Completed application forms should be posted to or hand delivered at the below mentioned addresses

2.4 The Department of Rural Development and Land Reform’s Service Provider Database will be used mainly for the purposes of identifying suppliers 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.

2.5 The Database will be solely used for the amount below 500 000.

2.6 It is the responsibility of a registered service provider to inform the Department of Rural Development and Land Reform immediately in writing of any changes in the particulars as stated in the application.

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

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

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

2.7.3 Failed to respond on requests for price quotations (three times per commodity)

2.7.4 The supplier being deregistered or blacklisted by National Treasury

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

2.7.6 It is advisable that the service providers provide the telephone numbers and email addresses

3

SECTION THREE : SUPPLIER INFORMATION

3.1 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

3.2 Company Addresses

Postal Address Town Region Code

Physical Address Town Region Code

3.3 Company Type

(Mark with an X in the applicable column)

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

If selected other, please specify: ________________________________________________________

__________________________________________________________________________________

4

3.4 Contact Person Details

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

3.5 Contact Addresses

Postal Address Town Region Code

Physical Address Town Region Code

3.6 Ownership of Company

Full Name Position in Company Identity Number Telephone Number Fax Number E-Mail Address Telephone Number Cell Phone Number Percentage Owned

Please indicate ownership on other Companies with percentage owned.

Name of Company Company Registration Nr Percentage Ownership

5

3.7 Supply Region and Town

Service Providers are required to select the Province and Towns they which to be registered for.

NB: Failure to indicate your Regions and Towns you are application will not be considered.

Regions Mark Towns( Mandatory) e.g. Region Town A, Town B Eastern Cape

Free State

Gauteng

Limpopo

Kwa-Zulu Natal

6

Mpumalanga

Northern Cape

Western Cape

Northwest

NB: Service Providers who which to select more than one province are required to demonstrate a footprint or proof that they can provide service to those provinces: a proof of water and lights accounts , contact details , physical address, fax and contact person. Refer to paragraph 2.7.3 on page 2.

7

OFFICE LIST FOR DATABASE DEVELOPMENT PHYSICAL ADDRESSES

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 14 Long Street Cape Town, 3dr Floor ,8000

021 409 0565/ 0529

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

18 Bell Towers Building, Bell 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 Office 61 Biccard , Cnr Grobler and Biccard Street, Polokwane

015 284 6347/6348

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

018 397 9600/55

10 North West Regional Land Claims Commission

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

018 389 9600/9620

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

012 432 4200

12 Head Office 184 Jeff Masemola Street, Old Building, Room 14D, Pretoria

012 312 9863/9463/9847/ 9206/8352

8

SECTION THREE : COMMODITIES

4. Commodities

Please indicate only three (3) in terms of your Core Business you can offer the Department of Rural Development and Land Reform.

Please note that Service Providers who select more than Three (3) Commodities will be disqualified

GOODS COMMODITY LIST

Tick

Agricultural Equipment and Accessories

Agricultural Supplies

Air Conditioning, Circulating and Heating Equipment

Accommodation Furniture and Furnishings

Communication Equipment and Accessories

Computer Hardware and Software

Bags and Cases

Cleaning Equipment and Supplies

Uniform

Groceries

Kitchen and Electrical Appliances and Supplies

Office Machines and Equipment and Supplies

Optical and Navigational Equipment

Medical Equipment and Supplies

Office Furniture and Furnishings

Photographic, Printing and Presentation Equipment and Supplies

Promotional Items and Gifts

Published Products

Property, Land and Temporary Shelter

9

Recreational and Sporting Equipment and Accessories

Safety and Security Equipment and Accessories

Stationery

Tools and General Equipment

Maintenance Supplies and Accessories

Surveying and Measuring Tools

Petroleum (Diesel and Petrol)

Sewing Equipment and Materials

SERVICES COMMODITY LIST

Auctioneer Services

Agricultural Support

Cleaning Services (Certification Required)

Community Support / Project Support

Construction Services (CIDB Certification Required)

Equipment Hire

Education and Training Services (Certification Required)

General Building Maintenance and Repair Services (Certification Required)

Health Services

Interior Decorating and Household Services

Information Technology Services

Land Tenure Specialists

Lease of Equipment and Machine

Logistical Services (Certificate of acceptability for food premises)

Management and Business Professionals and Administrative Services (Certification Required)

Monitoring and Evaluation

Human Resources Services

10

Legal Services (Certification Required)

Business Plan

Auditing Services (Certification Required)

Financial Services (Certification Required)

Research

Land Management Support

Land Reform Services

Land Surveying (Certification Required)

Publications, Communication and Information Services

Panel Services

Regional and Integrated Rural Development Planning

Relocation, Removals and Storage, Transportation and Mail Services

Security and Safety Services (Certification Required)

Telecommunication Services

Services and Repairs

Water Provision (Certification Required)

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

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

5. DECLARATION

I/We the undersigned declare that:

1. The information furnished is true and correct

2. The BBBEE Claimed is in accordance with the General Condition.

-------------------------------------------------- ----------------------------------------

Signature of Owner or Authorised Date

Representative

SBD 2

TAX CLEARANCE CERTIFICATE REQUIREMENTS

It is a condition of bid that the taxes of the successful bidder must be in order, or that satisfactory arrangements have been made with South African Revenue Service (SARS) to meet the bidder’s tax obligations. 1 In order to meet this requirement bidders are required to complete in full the attached form TCC 001

“Application for a Tax Clearance Certificate” and submit it to any SARS branch office nationally. The Tax Clearance Certificate Requirements are also applicable to foreign bidders / individuals who wish to submit bids.

2 SARS will then furnish the bidder with a Tax Clearance Certificate that will be valid for a period of 1 (one) year

from the date of approval. 3 The original Tax Clearance Certificate must be submitted together with the bid. Failure to submit the original

and valid Tax Clearance Certificate will result in the invalidation of the bid. Certified copies of the Tax Clearance Certificate will not be acceptable.

4 In bids where Consortia / Joint Ventures / Sub-contractors are involved, each party must submit a separate

Tax Clearance Certificate. 5 Copies of the TCC 001 “Application for a Tax Clearance Certificate” form are available from any SARS branch

office nationally or on the website www.sars.gov.za. 6 Applications for the Tax Clearance Certificates may also be made via eFiling. In order to use this provision,

taxpayers will need to register with SARS as eFilers through the website www.sars.gov.za. Jeyrel:\Mdk416-SBD2 tax clearance

Page 12 of 22

TCC 001 TAX CLEARANCE

Application for a Tax Clearance Certificate

Name/Legal name(Initials & Surname or registered name)

Surname

Particulars of applicant

Purpose

Particulars of representative (Public Officer/Trustee/Partner)

Trading name (if applicable)

First names

VAT registration no

Customs code

Income Tax ref no

Income Tax ref no

PAYE ref no

SDL ref no

UIF ref no

Page 1 of 2

ID/Passport no

ID/Passport no

Company/Close Corp. registered no

4

7

L

U

Telephone no

Telephone no

Physical address

Physical address

Postal address

E-mail address

E-mail address

Fax no

Fax no

C O D E

C O D E

N U M B E R

N U M B E R

C O D E

C O D E

N U M B E R

N U M B E R

If “Good standing”, please state the purpose of this application

Select the applicable option Tenders Good standing

Page 13 of 22

Page 2 of 2

Particulars of the 3 largest contracts previously awarded

Particulars of tender (If applicable)

Audit

Date started

I the undersigned confirm that I require a Tax Clearance Certificate in respect of Tenders or Goodstanding.

I hereby authorise and instruct to apply to and receive from SARS the applicable Tax Clearance Certificate on my/our behalf.

Appointment of representative/agent (Power of Attorney)

Date finalised Principal Contact person Telephone number Amount

Name of representative/ agent

Name of applicant/ Public Officer

Signature of representative/agent

Signature of applicant/Public Officer

Date

Date

Expected duration of the tender

Estimated Tender amount

Are you currently aware of any Audit investigation against you/the company?If “YES” provide details

Tender number

R ,

year(s)

C C Y Y

C C Y Y

M M

M M

D D

D D

YES NO

Notes:

1. It is a serious offence to make a false declaration.

2. Section 75 of the Income Tax Act, 1962, states: Any person who

(a) fails or neglects to furnish, file or submit any return or document as and when required by or under this Act; or

(b) without just cause shown by him, refuses or neglects to-

(i) furnish, produce or make available any information, documents or things;

(ii) reply to or answer truly and fully, any questions put to him ...

As and when required in terms of this Act ... shall be guilty of an offence ...

3. SARS will, under no circumstances, issue a Tax Clearance Certificate unless this form is completed in full.

4. Your Tax Clearance Certificate will only be issued on presentation of your South African Identity Document or Passport (Foreigners only) as applicable.

Declaration

I declare that the information furnished in this application as well as any supporting documents is true and correct in every respect.

Page 14 of 22

ANNEXURE B SBD 4

DECLARATION OF INTEREST

1. Any legal person, including persons employed by the state¹, or persons having a kinship with

persons employed by the state, including a blood relationship, may make an offer or offers in terms of this invitation to bid (includes an advertised competitive bid, a limited bid, a proposal or written price quotation). In view of possible allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons employed by the state, or to persons connected with or related to them, it is required that the bidder or his/her authorised representative declare his/her position in relation to the evaluating/adjudicating authority where-

- the bidder is employed by the state; and/or - the legal person on whose behalf the bidding document is signed, has a relationship with

persons/a person who are/is involved in the evaluation and or adjudication of the bid(s), or where it is known that such a relationship exists between the person or persons for or on whose behalf the declarant acts and persons who are involved with the evaluation and or adjudication of the bid.

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

submitted with the bid. 2.1 Full Name of bidder or his or her representative: …………………………………………………………. 2.2 Identity Number:………………………………………………………………………………………………... 2.3 Position occupied in 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 / members, their individual identity numbers, tax

reference numbers and, if applicable, employee / PERSAL numbers must be indicated in paragraph 3 below.

¹“State” means – (a) any national or provincial department, national or provincial public entity or constitutional institution within the meaning of the Public Finance

Management Act, 1999 (Act No. 1 of 1999); (b) any municipality or municipal entity; (c) provincial legislature; (d) national Assembly or the national Council of provinces; or (e) Parliament. ²”Shareholder” means a person who owns shares in the company and is actively involved in the management of the enterprise or business and exercises control over

the enterprise.

Page 15 of 22

2.7 Are you or any person connected with the bidder YES / NO presently employed by the state? 2.7.1 If so, furnish the following particulars:

Name of person / director / trustee / shareholder/ member: ……....……………………………… Name of state institution at which you or the person connected to the bidder is employed : ……………………………………… Position occupied in the state institution: ……………………………………… Any other particulars: ………………………………………………………………

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

2.7.2 If you are presently employed by the state, did you obtain YES / NO

the appropriate authority to undertake remunerative work outside employment in the public sector?

2.7.2.1 If yes, did you attach proof of such authority to the bid YES / NO

document? (Note: Failure to submit proof of such authority, where applicable, may result in the disqualification of the bid.

2.7.2.2 If no, furnish reasons for non-submission of such proof:

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

2.8 Did you or your spouse, or any of the company’s directors / YES / NO trustees / shareholders / members or their spouses conduct business with the state in the previous twelve months?

2.8.1 If so, furnish particulars:

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

2.9 Do you, or any person connected with the bidder, have YES / NO any relationship (family, friend, other) with a person employed by the state and who may be involved with the evaluation and or adjudication of this bid?

2.9.1 If so, furnish particulars. ……………………………………………………………...

Page 16 of 22

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

2.10 Are you, or any person connected with the bidder, YES/NO

aware of any relationship (family, friend, other) between any other bidder and any person employed by the state who may be involved with the evaluation and or adjudication of this bid?

2.10.1 If so, furnish particulars.

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

2.11 Do you or any of the directors / trustees / shareholders / members YES/NO

of the company have any interest in any other related companies whether or not they are bidding for this contract?

2.11.1 If so, furnish particulars: ……………………………………………………………………………. ……………………………………………………………………………. …………………………………………………………………………….

3 Full details of directors / trustees / members / shareholders. Full Name Identity

Number Personal Income Tax Reference Number

State Employee Number / Persal Number

Page 17 of 22

4 DECLARATION

I, THE UNDERSIGNED (NAME)………………………………………………………………………

CERTIFY THAT THE INFORMATION FURNISHED IN PARAGRAPHS 2 and 3 ABOVE IS CORRECT. I ACCEPT THAT THE STATE MAY REJECT THE BID OR ACT AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE. ………………………………….. ..…………………………………………… Signature Date …………………………………. ……………………………………………… Position Name of bidder

November 2011

Page 18 of 22

SBD 8

DECLARATION OF BIDDER’S PAST SUPPLY CHAIN MANAGEMENT

PRACTICES

1 This Standard Bidding Document must form part of all bids invited. 2 It serves as a declaration to be used by institutions in ensuring that when goods

and services are being procured, all reasonable steps are taken to combat the abuse of the supply chain management system.

3 The bid of any bidder may be disregarded if that bidder, or any of its directors

have-

a. abused the institution’s supply chain management system; b. committed fraud or any other improper conduct in relation to such system; or c. failed to perform on any previous contract.

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

Item Question Yes No 4.1 Is the bidder or any of its directors listed on the National Treasury’s Database of

Restricted Suppliers as companies or persons prohibited from doing business with the public sector? (Companies or persons who are listed on this Database were informed in writing of this restriction by the Accounting Officer/Authority of the institution that imposed the restriction after the audi alteram partem rule was applied). The Database of Restricted Suppliers now resides on the National Treasury’s website(www.treasury.gov.za) and can be accessed by clicking on its link at the bottom of the home page.

Yes

No

4.1.1 If so, furnish particulars:

4.2 Is the bidder or any of its directors listed on the Register for Tender Defaulters in terms of section 29 of the Prevention and Combating of Corrupt Activities Act (No 12 of 2004)? The Register for Tender Defaulters can be accessed on the National Treasury’s website (www.treasury.gov.za) by clicking on its link at the bottom of the home page.

Yes

No

4.2.1 If so, furnish particulars:

4.3 Was the bidder or any of its directors convicted by a court of law (including a court outside of the Republic of South Africa) for fraud or corruption during the past five years?

Yes

No

4.3.1 If so, furnish particulars:

Page 19 of 22

4.4 Was any contract between the bidder and any organ of state terminated during the past fi ve years on account of failure to perform on or comply with the contract?

Yes

No

4.4.1 If so, furnish particulars:

SBD 8

CERTIFICATION

I, THE UNDERSIGNED (FULL NAME)…………………………………………………

CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS TRUE AND CORRECT.

I ACCEPT THAT, IN ADDITION TO CANCELLATION OF A CONTRACT,

ACTION MAY BE TAKEN AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE.

………………………………………... ………………………….. Signature Date

………………………………………. ………………………….. Position Name of Bidder

Js365bW

Page 20 of 22

PW1423

Captured By:

Date Captured:

Authorised By:

Date Authorised:

Supplier code:

Enquiries. :

BAS PMIS LOGIS WCS Tel. No.:

OFFICE: ……………………………

The Director General : National TreasuryDEPT OF RURAL DEVELOPMENT AND LAND REFORMI/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 thirty days notice by prepaid registered post. Please ensure information is validate 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 responsibiliy for any delayed payments, as a result of

incorrect information supplied.

Trading Name

Tax Number

VAT Number

First Name:

Surname:

Street Address

Postal Code

New Supplier information Update Supplier information

Supplier Type: Individual Department Partnership

Company Trust

CC Other ( Specify )

Department Number

Postal Address

New Detail

DEPARTMENT OF RURAL

DEVELOPMENT AND LAND

REFORM

Head Office Only

Company / Personal Details

SUPPLIER MAINTENANCE:

CONTRACTOR

CONSULTANT

Registered Name

Title:

Initials:

Postal and Street Address Detail of the Company / Individual

Page 21 of 22

PW1423

This field is compulsory and should be completed by a bank official from the relevant bank

Account Number

Branch Name

Branch Number

Cheque Account

Savings Account

Transmission Account

Bond Account

Other (Please Specify)

ID Number

Passport Number

Company Registration Number / /

*CC Registration

*Please include CC/CK where applicable

Practise Number

Bank stamp

It is hereby confirmed that this details have been verified

against the following screens

ABSA-CIF screen

FNB- Hogans system on the CIS4/CUPR

STD Bank-Look-up-screen

Nedbank- Banking Platform under the Client Details Tab

Business

Area Code Telephone Number Extension

Home

Area Code Telephone Number Extension

Fax

Area Code Fax Number

Cell

Cell Code Cell Number

Email Address

Adress of Rural Development and Land Reform

Office where form is submitted from

/ / / /Date (dd/mm/yyyy) Date (dd/mm/yyyy)

NB: All relevant fields must be completed

Account Type

Account Name

Supplier Account Details

Contact Details

Contact Person:

Supplier Signature Departmental Official

Print Name Print Name

Rank

Page 22 of 22