The purpose of this database is to give all prospective suppliers an equal opportunity to submit quotations.

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1 TO ALL SUPPLIERS SEEKING REGISTRATION AS APPROVED SUPPLIERS ON DEPARTMENT OF CORRECTIONAL SERVICE S SUPPLIER DATABASE FOR THE PERIOD 1 APRIL 2015 TO MARCH 2016 The purpose of this database is to give all prospective suppliers an equal opportunity to submit quotations. All suppliers are herewith invited to register on Department of Correctional Service s supplier database. Attached please find an official application form to assist the department in updating the database as required by legislation. The following important notes should be read carefully prior to completion of this form 1. This form must be completed in full and signed by the owner(s) or director or administration head. 2. Full signature is required when alterations are made in this document. 3. If the information required is not applicable to your business, clearly insert N/A in the appropriate space. 4. Mark the appropriate square with an 'X' where it is applicable to you. 5. All fields on application form MUST be completed by applicant; if the space provided is left blank, it will be regarded as information that is still outstanding and you will invalidate your application 6. faxed or ed application forms will be accepted. 7. Businesses providing information intentionally incorrectly or fraudulently will be disqualified. 8. Businesses blacklisted by any organs of state* must first be removed or cleared from blacklist before registration. 9. A maximum of three commodities must be indicated 10. The following documents must be attached to this application form: Original valid Tax Clearance Certificate Proof of company registration - CIPC Certified ID copy/ies for all company members/partners/directors. VAT registration certificate (for VAT vendors only); BEE Rating Certificate, if available Company profile If members/directors/partners/owners are employed by the state, proof that they are allowed to conduct business outside remunerative work should be attached Failure to submit all the above documents will invalidate the application. 11. Members / directors / partners / owners in service with any organ of state* management; must declare any conflict of interest. Failure to do so may lead to disqualification or de-registration. 12. This is only a registration form for database and does not guarantee any award of bid / contract. 13. The Department of Correctional Services reserves the right to reject any application, which in its opinion failed to comply with the registration requirements or criteria. 14. Completed Suppliers Database Application forms and all required documents must be posted or hand delivered to: Dept. of Correctional Services Dept. of Correctional Services Poytons Building West Block Services Private Bag x FW Nkomo & Sophie De Bruin Pretoria ZssSServices Pretoria OR 0001

2 DEPARTMENT OF CORRECTIONALSERVICES SUPPLIER DATABASE REGISTRATION NAME OF SERVICE PROVIDER: FOR OFFICIAL PURPOSE SUPPLIER NUMBER Application Accepted Application Rejected Captured By: Signature: Date: Verified By: Signature: Date:

3 SUPPLIER APPLICATION FORM Supplier detail: Company / Supplier Name: Trading Name if different from the above: Company / Close Corporation Registration Number # VAT registration number (if applicable): Income tax reference number ## Web Address: Address: Telephone Number: Fax Number: (compulsory) Toll Free Number: Number of full time employees: # For Companies and Close Corporations, as with the Registrar of Companies / CC ## Insert Personal Income Tax Number for sole proprietor of Personal Income Tax numbers for all parties in terms of partnerships Postal Address: (compulsory) Physical Address :( compulsory) Postal Code: Company/Supplier Classification: (Please X the relevant box or boxes) ISO Listed Importer Services Manufacturer Repairer Black Owned (Please X the relevant box) Distributor Exporter Sales Tax Clearance Certificate Attached Expiry date Supplier Grouping Detail: Type of Firm: (Please X the relevant box) 1 Public Company (Ltd) 2 Private company (Pty) Ltd 3 Closed Corporation (cc) 4 Other (specify) 5 Joint Venture 6 Consortium 7 Sole Proprietor 8 Foreign Company 9 Partnership 10 Trust 11 Section 21 Company 12 Government / Organ of state / Parastatals

4 Main contact person in your company: (Director) Name: Company Position: Cell phone Number: Fax Number: address: Contact person (sales) in your company: Name: Position in company: Cell Phone Number: Fax Number: address: Preferred method of correspondence Fax Telephone 5. Broad-Based Black Economic Empowerment (B-BBEE) information (Please mark with an X your B-BBEE credentials) B-BBEE Status B-BBEE Score/Qualification B-BBEE Recognition level % Level 1 Contributor > % Level 2 Contributor > 85 but < % Level 3 Contributor > 75 but < % Level 4 Contributor > 65 but < % Level 5 Contributor > 55 but < 65 80% Level 6 Contributor > 45 but < 55 60% Level 7 Contributor > 40 but < 45 50% Level 8 Contributor > 30 but < 40 10% n-compliant Contributor < 30 on the Scorecard 0% Qualifying Small Enterprise (QSE) Please mark with an X your B-BBEE credentials Any enterprise with an annual total revenue of between R5 million and R35 million qualifies as a Qualifying Small Enterprise. Enterprise 50% or more Black owned Please mark with an X your BBBEE credentials % Provide % of shareholding Indicate if your enterprise is 50% or more black owned Enterprise 30% or more Black women Please mark with an X your B-BBEE credentials % Provide % of shareholding Indicate if your enterprise is 30% or more black women owned I/We confirm that the information provided is correct as at this date: Name Signature Designation Date

5 List all Shareholders by Name, Position, Identity Number and Citizenship (Compulsory) Name Position occupied in the Enterprise Identity Number Citizenship 5

6 DECLARATION OF INTEREST (SBD4) (NB : In accordance with Sections 118 and 121 of the Correctional Services Act, 1998 (Act. 111 of 1998), no member of the Department of Correctional Services may participate in the bidding process of the Department) 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 a price quotation, advertised competitive bid, limited bid or proposal). 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 and/or take an oath declaring his/her interest, 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, shareholder, member) : 2.4 Registration number of company, enterprise, close corporation, partnership agreement or trust : 2.5 Tax Reference Number :

7 2.6 VAT Registration Number : The names of all directors / trustees / shareholders² / 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. 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. 2.7 Are you or any person connected with the bidder, presently employed by the state? If so, furnish the following particulars : Name of person/ director/ shareholder/ member Name of state institution to which the person is connected Position occupied in the state institution Any other particulars :.....

8 If you are presently employed by the state, did you obtain the appropriate authority to undertake remunerative work outside employment in the public sector? If yes, did you attach proof of such authority to the bid document? (te : Failure to submit proof of such authority, where applicable, may result in the disqualification of the bid.) If no, furnish reasons for non-submission of such proof : Did you or your spouse, or any of the company s directors/shareholders/members or their spouses conduct business with the state in the previous twelve (12) months? If so, furnish particulars : Do you, or any person connected with the bidder, have 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?

9 2.9.1 If so, furnish particulars : Name of person/ director/ shareholder/ member Name of state institution to which the person is connected Position occupied in the state institution Nature of relationship 2.10 Are you, or any person connected with the bidder, aware of any relationship (family, friend, other) between the bidder and any person employed by the state who may be involved with the evaluation and or adjudication of this bid? If so, furnish particulars : Name of person/ director/ shareholder/ member Name of state institution to which the person is connected Position occupied in the state institution Nature of relationship 2.11 Do you or any of the directors/shareholders/members of the company have any interest in any other related companies whether or not they are bidding for this contract? If so, furnish particulars :.....

10 Full details of directors / trustees / members / shareholders : Full name Identity number* Personal Tax Reference Number State Employee Number / Persal Number *Copies of Identity Document must be attached. DECLARATION I, THE UNDERSIGNED (NAME) CERTIFY THAT THE INFORMATION FURNISHED IN PARAGRAPH 2 TO 3 ABOVE IS CORRECT. I ACCEPT THAT THE STATE MAY REJECT THE BID OR ACT AGAINST ME IN TERMS OF PARAGRAPH 23 OF THE GENERAL CONDITIONS OF CONTRACT SHOULD THE DECLARATION PROVE TO BE FALSE. SIGNATURE. DATE.

11 POSITION NAME OF BIDDER te : Should the bidder or any of its directors/members or shareholders be employees of any organ of state as contemplated in the Preferential Procurement Policy Framework Act, 2000 (Act 5 of 2000), such member/director or shareholder must submit a certified copy of the permission granted by the Executive Authority of his/her Department to conduct remunerative work in the Public Service as contemplated in the Public Service Act, 1994 (Act 103 of 1994) Chapter VII, Sections 30 and 31. Failure to submit the proof will automatically invalidate the bid. Knowingly not submitting it will make the person liable for fraud.

12 DECLARATION OF BIDDER S PAST SUPPLY CHAIN MANAGEMENT PRACTICES (SBD8) 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 Is the bidder or any of its directors listed on the National Treasury s database as companies or persons prohibited from doing business with the public sector? 6 7 (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). 8 9 The Database of Restricted Suppliers now resides on the National Treasury s website ( and can be accessed by clicking on its link at the bottom of the page 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 ( 12 of 2004)? The Register for Tender Defaulters can be accessed on National Treasury s website, ( by clicking on its link at the bottom of the home page 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? If so, furnish particulars: 4.4 Was any contract between the bidder and any organ of state terminated during the past five years on account of failure to perform on or comply with the contract?

13 4.4.1 If so, furnish particulars: 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. Position.. Date.. Name of Bidder

14 LIST OF COMMODITIES DESCRIPTION OF COMMODITY: X DESCRIPTION OF COMMODITY: X AIR CONDITIONING including installation and repairs ( Proof of registration as an electrician NEWSPAPERS DISTRIBUTORS AUDIO-VISUAL AIDS & EQUIPMENT FORENSIC AUDIT/ INVESTIGATIONS BAGS OFFICE FURNITURE AND EQUIPMENT OFFICE STATIONERY PEST CONTROL SERVICES BLINDS CATERING SERVICES( Municipal Certificate Of Acceptability- Health Certificate required) CORPORATE CLOTHING N AL CORPORATE GIFTS AND BRANDING CURTAINING/RAILS & ACCESSORIES COMPUTER CONSUMABLES EVENT MANAGEMENT INSTALLATION OF DSTV INSTALLATION OF CARPET INSTALLATION OF WOODEN FLOORS SECURITY EQUIPMENT AND PRODUCTS SPORT EQUIPMENT TRAINING SERVICES( Proof of SETA or SAQA Accreditation TRANSLATION SERVICES SAQA SAQA KITCHEN APPLIANCES( FRIDGES, MICROVEN, WATER COOLERS) LIBRARY BOOKS/ PUBLICATIONS, LOCKSMITHS/ SUPPLY / INSTALLATION OF SECURITY LOCKS te: Commodities not listed will be added if relevant

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17 CERTIFICATION OF FINANCIAL ABILITY AND STABILITY (Paragraph... of the Special Conditions of Contract) Important: This form must be completed and submitted together with the Bid. Failure to do so will invalidate your bid. To be completed by bidder: BID NO.: Price Quotations DESCRIPTION: Price Quotations up to R NAME OF BIDDER: N/A TOTAL BID PRICE: N/A To be completed by bank/financial institution: This information is issued without prejudice to any registered bank/financial institution and the bank/financial institution reserves all their rights in this regard. bank/financial institution will be held liable for any loss or damage that any person may suffer as a result of any reliance being placed on the information provided. Mr/Mrs/Miss... (Client name) holds a (current/savings) account in his/her name with... (Name of bank) for... years. The banking details of such account:

18 Account number: Branch: Branch code: It is hereby certified that (Client name) has the financial ability and stability to successfully execute this contract, taking the note below into account. Please note that the standard payment condition applicable to Government contracts stipulate the following: Payments shall be made promptly by the purchaser, but in no case later than thirty (30) days after submission of an invoice or claim by the supplier. The information supplied is on the strictest and most confidential grounds. NAME OF FINANCIAL INSTITUTION: ADDRESS: TELEPHONE NUMBER : SIGNATURE : CAPACITY : DATE : BANK STAMP AND DATE

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