APPLICATION FORM TO REGISTER ON THE SERVICE PROVIDER DATABASE OF THE DEPARTMENT OF RURAL DEVELOPMENT AND LAND REFORM

Transcription

1 APPLICATION FORM TO REGISTER ON THE SERVICE PROVIDER DATABASE OF THE DEPARTMENT OF RURAL DEVELOPMENT AND LAND REFORM SMMEs and Historically Disadvantaged Individuals with expertise are particularly encouraged to apply.

2 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. 1

3 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 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 2

4 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 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: 3

5 2.4 Contact Person Details Contact Person Full Name Position in Company Identity Number Telephone Number Fax Number 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 4

6 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 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 Tick 5

7 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 6

8 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 7

9 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 8

10 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 9

11 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 10

12 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 11

13 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 12

14 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 13

15 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 14

16 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 15

17 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 16

18 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

19 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 18

20 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 African Coloured Indian Percentage Owned 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 19

21 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 20

22 SECTION FOUR : OFFICE LIST FOR DATABASE DEVELOPMENT 4.1 OFFICE PHYSICAL ADDRESS CONTACT NUMBERS 1 PSSC: KwaZulu Natal 270 Jabu Ndlovu Street, /6546 Pietermaritzberg 2 PSSC: Eastern Cape Block H, Ocean Terrace Quigney, East London 3 PSSC: Western Cape Van der sterr Bulding, Rhodes /4482 Avenue, Mowbray 4 PSSC: Free State SA Eagle Building,136 Maitland / 6140 Street, Bloemfontein 5 PSSC: Northern Cape Corner Knight and Stead Street 6 th /4041 Floor New Public Building, Kimberley 6 Mpumalanga Provincial Home Affairs Building 4 th Floor Cnr Land Reform Office Henshall & Andrew Street, Nelspruit 7 Mpumalanga Regional 30 Samora Machel Drive, Restitution /6088 Land Claims Commission House, Nelpruit Limpopo Provincial Land Andria Building, Second floor, Cnr Reform Office Schoeman and Rissik Street, Polokwane 11 Limpopo Regional Land Kagiso House, Cnr Schoeman & Claims Commission Rissik Street, Polokwane 12 PSSC: North West Shama Investment Building North West Regional Land Claims Commission Shippard, Mafikeng ABSA Building, Ground Floor, Cnr Provident & University Drive, Mmabatho / PSSC: Gauteng 1145 Burnett Street, Hatfield, Pretoria Gauteng Regional Land 9 Bailey Lane, Arcadia, Pretoria /6526 Claims Commission 16 Head Office 184 Jacob Mare Street, Old Building, Room 14D, Pretoria /