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.

� 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.

� Valid and original tax clearance certificate.

NB: 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 authorises 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 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 Reform’s 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 BBBEE status of the entity. Should a contract be awarded to an entity as a result of incorrect particulars on the status of an 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 Regulation, cancel the contract and to claim for 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

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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 Parastetal Non-Governmental Organisation Other

If selected other, please specify: ________________________________________________________

__________________________________________________________________________________

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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 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

6

2.8 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.

Service Providers are limited to Three (3) Commodities NB: (Please note that the highlighted areas in BOLD are commodities and sub-commodities are listed below, therefore you may select all sub-commodities under one commodity.)

ANNEXURE A

List of Goods Commodities

Tick

Agricultural Equipment and Accessories

Agricultural Equipment

Agricultural Accessories

Irrigation system and Equipment

Farm Implements

Agricultural Supplies

Live Animals

Animal Feed

Seeds, Bulbs, Seedlings and Cuttings

Fertilizers, Plant Nutrients and Herbicides

Pest Control Products

Farm tools, spades, rakes

Air Conditioning, Circulating and Heating Equipment

Air Conditioner

Air Conditioner Regulator

Air Circulating Ventilator

Fans

Heaters

Air treatment : purifier, humifier, dehumidifier

7

Cold & Freezer room Installation, Maintenance and repair

Accommodation Furniture and Furnishings

Reception Chairs and Couches

Benches

Carpet

Blinds and Curtains

Accommodation Furnishings

Outdoor Furniture and Furnishings

Tables

Communication Equipment and Accessories

Communication Devices and Accessories

Communication Equipment

Mics

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

8

Carry Bags

Cases

Luggage and Travelling Bags

Equipment Cases

Cleaning Equipment and Supplies

Cleaning Equipment

Cleaning Supplies

Hygiene Supplies

Protective Gear

Fire Equipment

Fire Beater

Fire Trailer Water Pump

Vent Fire Knap Sack Spray

Wooden Handle Fire Beater

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

9

Beverages

Bread and Bakery products

Groceries and Vegetables

Dairy Products

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

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

10

Boardroom Tables

Office Furnishings

Tables and Counter Tops

TV Screen

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

Promotional Items and Gifts

Corporate Gifts

Promotional Items

Displays and Stands

Published Products

Printed Media

Electronic Reference Material

Signage and Accessories

Engravers

Property, Land and Temporary Shelter

Prefab House

Mobile House

Shelter

Land

Fixed Property

Poultry House

Recreational and Sporting Equipment and Accessories

11

Sports Equipment and Accessories

Sports Kit

Jumping castle

Swimming pool

Safety and Security Equipment and Accessories

Safety Equipment

Security Accessories

Alarm and Security Systems

Locks and Handles

Fire Extinguisher

Security Gates and Bugler doors

Biometric reader

Smoke Sensor

X-ray Equipment

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

File Dividers and Indexes

Glue, Labels and Tapes

Markers and Highlighters

Paper and Board

Pens and Refills

12

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

Grinding, Cutting and Sharpening Equipment

Scaffolding and Ladders

Sliding Gates

Swing Gates

Barricades

Gate Automation

Artwork Equipment

Audio Visual Equipment (Screen and Sounds)

Maintenance Supplies and Accessories

Electrical Supplies

Plumbing Supplies

General Maintenance Supplies and Accessories

Surveying and Measuring Tools

Surveying Tools

Measuring Tools

Cartographic

13

Petroleum

Diesel

Transmission oil, Hydraulic oil, Brake fluid

List of Services Commodities

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

14

Carpet Cleaning Services

Garden and Plant Maintenance Services

Vehicle Cleaning Services

Waste Management Services

Community Support / Project Support

Legal Entity Establishment

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, Road Markings, Bridges

Mechanical - Engineers

Fencing – Including Material and Installation, Steel Security Fencing Concrete- SQ

Structural Renovation

Paving and Drive Ways

Fabricators, structural Steelwork Fabrication and Erection SL

Roofing

Tilling

Car Ports

Asphalt Works Supply and Lay-SB

Disaster Management Training

Training in Fire Prevention

Training in Thunderstorm

15

Training in Drought

Training in Floods

Training in Fire Protection

Training in Handling Dangerous Goods

Training in Environmental Management

Equipment Hire

Catering Equipment

Construction Equipment

Earthmoving Equipment

General Equipment

Tents and Marques

Musical Equipment

Plants

Education and Training Services (Certification Required)

Professional Training

Alternative Educational Systems

Educational Institutions

Specialized Educational Services

Training Courses (Agri Sector e.g. Soil Rehabilitation)

Training (Construction Sector)

Training (Gender)

Training (Sign Language Interpreters)

Training in Soil Rehabilitation

General Building Maintenance and Repair Services (Certification Required)

Locksmith Services

Partitioning Services

16

Window Services

Fumigation Services

Pest Control Services

Electrical Services

Plumbing Services

Welding Services

Health Services

Wellness Services

Occupational Health & Safety

Ambulance Services

First Aid Training

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

Plants Hire and Maintenance

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

17

Adaptive technology for Blinds and Visually Impaired

Land Tenure Specialists

Rights Enquiries

Act Commissioners

Lease of Equipment and Machine

Beverage Vending Machine

Photocopy Machine

Water Coolers

Logistical Services

Catering Services

Exhibition Centre and Meeting Facilities

Event Management Services

Bed and Breakfast

Flight Reservations

Accommodation

Seminars/ Workshops/ Conferences

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

Policy Expert : Green and White Paper

Monitoring and Evaluation

18

Land Reform Programme Management M&E

Project Monitoring and Evaluation

Organisational Monitoring and Evaluation

Diagnostic Evaluation Studies

Indicator Protocols

Monitors and Evaluation Software

Human Resources Services

Affirmative Management

Change Management

Discipline, Grievances and Dispute Resolutions

Personnel Placement (Recruitment) Agencies

Work Study

Competency Skills

Facilitation

Gender Equity Specialist Services

Data Captures

Administrators

Network Controllers

Centennial Systems Integrator’s

Training of Trainers

Rural Development Coordinator

Conflict Management

Response Handling

Credentials Verification

Performance Management

Skills Audit

Competency Test

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Psychometric Test

Training in GIS

Human Resources Development Services

Human Resources Management Services

Legal Services (Certification Required)

Conveyance

Notaries / Notary Public

Land Legal Specialist

Land Reform Law Specialist

Land Reform Mediator

Legal Advisor

Drafters

Legal Entities Specialist

Discipline, Grievance and Dispute Resolutions

Labour Law Specialist

Commercial Law

Arbitrators

Business Plan

Business Plan

Auditing Services (Certification Required)

Financial and operational Audit

Forensic and Investigation Audit

Information Technology Forensic Audit

Information technology Audit

Legal Compliance Audit

Performance Management Audit

20

Financial Services (Certification Required)

Business and Financial Advisory Services

Finance Systems Designing Services

Charted Accounts Services

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

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

Books

Marketing

Video Coverage

Multi-Media

Writing and Translations Services

Printing and Reproduction Services

21

Photographic Services

Graphic Design Services

Solar Installation and Services

Solar Installation and Repairs

Town and Regional Integrated Rural Development Planning

Regional and Integrated Rural Development Planning

Township Establishment

Engineering Support

Environmental Impact Assessment / Environmental Scoping

Land Use Planning

Spatial Planning

Consolidation, Sub-divisions and Registration of Servitudes

Relocation, Removals and Storage, Transportation and Mail Services

Courier Services (Mail and Cargo Transport)

Driving School

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

Security and Safety Services (Certification Required)

Security and Personal Safety

Security Surveying Services

Hardware and Software : Installation, Replacement and Labour

CCTV Camera

Telecommunication Services

22

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

Duct Installation

Repair od Sound

Engine services (Car service)

Repair and Installation of Glasses

Water Provision (Certification Required)

Water Provision Contractors / Consultants

Borehole Construction

Water Tanks

Pump Stations

Reservoir

Water Reticulation

Sewerage Systems

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

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

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

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

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

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2.9 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

SECTION THREE : BBBEE DECLARATION

3.1 Equity Ownership

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

Group Male Female Disabled African Coloured Indian White

3.2 BEE

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

Group Percentage Owned African Coloured Indian White

3.3 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?)

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3.4 SMME Status

(Mark with an X in the applicable column)

Micro Small Medium Large

4. 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 Conditions.

3. Any conflict of interest was declared.

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

Signature of Owner or Authorized Date

Representative

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SECTION FOUR : OFFICE LIST FOR DATABASE DEVELOPMENT

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 9864/9463/9847