PLEASE READ BEFORE COMPLETING THIS FORM

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1 PLEASE READ BEFORE COMPLETING THIS FORM In order to finalize the processing of your supplier database registration with the JGDM, the following information needs to be submitted together with your complete supplier registration form: Company registration documents Certified Identity Documents of directors/ members/ shareholders Valid tax clearance certificate Municipal Levy Clearance from Municipality where business is operating, if applicable Valid proof of business address (not older than 3 months) Proof of Registration with relevant Professional Body, if applicable BBBEE Verification Certificate Company Profile All posted documents/original application form should be addressed to: The Supply Chain Manager Joe Gqabi District Municipality Private Bag 102 Barkly East 9786 All supplier registration enquiries shall be directed to: (T) / (F) Website: SECTION A: BUSINESS INFORMATION Trading Name: Registered Name: Registration Number: VAT Registration Number:

2 Type of Enterprise: Close corporation Partnership Company (Pty) Limited Consortium Cooperative Trust Partnership Sole Trader (one person business) Other (Specify) Income Tax Reference Number: Personal Income Tax Number: (for sole traders only) Type of services / products: SECTION B: BUSINESS BANKING DETAILS Name of Account Holder: Account Number: Type of account: Branch Code: Branch Name: Bank Stamp SECTION C: EQUITY AND OWNERSHIP DETAILS Details Percentage (%) Ownership Percentage By: Blacks: Women: People living with disability: Management Percentage By: Management percentage by historically disadvantaged individuals (HDIs):

3 SHAREHOLDERS: Shareholder 1 Full Names: Identity Number: Gender Percentage Ownership: Shareholder 2 Full Names: Identity Number: Gender Percentage Ownership: Shareholder 3 Full Names: Identity Number: Gender Percentage Ownership:

4 Shareholder 4 Name: Identity Number: Gender Percentage Ownership: Please Note: If more than 4 shareholders/directors please submit relevant proof documentation. SECTION D: BUSINESS CONTACT DETAILS Head Office Physical Address: Branch Office Physical Address: Postal Address: Business Tel: Business Fax: Business

5 SECTION E: PARTICULARS OF REPRESENTATIVE Full Names: Position: Identity Number: Nationality: Postal Address: Physical Address: Telephone: Fax: Marital Status (Please Tick): Single Married Divorced Widowed Type of Marriage: Customary In-Community of Property Out-of-Community of Property Number of dependants: SECTION F: BUSINESS TRADE REFERENCES (FOR PHUMELELA PARTICIPANTS) Company 1: Name: Account Number: Current Balance: Telephone:

6 Company 2: Name: Account Number: Current Balance: Telephone: SECTION G: BUSINESS PROJECT REFERENCES Company 1: Employer/Client: Nature of Work: Value of Work: Completion Date: Contact Details: Company 2: Employer: Nature of Work: Value of Work: Completion: Contact Details: Company 3: Employer: Nature of Work: Value of Work: Completion: Contact Person:

7 SECTION H: MANDATORY DECLARATIONS DECLARATION (1) OF INTERESTS (KINSHIP, RELATIONSHIP WITH PERSONS EMPLOYED BY JGDM AND EMPLOYMENT BY STATE ORGANS 1. Do you, or any person have any relationship (family, friend, other) with a person employed with the JGDM or its Administration and who may be involved with the evaluation, preparation and/or adjudication of any bid? No Yes If YES, please state particulars: 2. Are you or any other person connected with this application, employed by any organ of State? No Yes If YES, please state particulars: SIGNATURE OF DECLARER DATE POSITION OF DECLARER NAME OF COMPANY DECLARATION (2) (VALIDITY OF INFORMATION PROVIDED) I.declare that the information provided is true and correct, the signature to this application is duly authorized and documentary proof regarding any bidding issue will, when required, be submitted to the satisfaction of the Joe Gqabi District Municipality SIGNATURE OF DECLARER DATE POSITION OF DECLARER NAME OF COMPANY OF SERVICE PROVIDER

8 FOR INTERNAL OFFICE USE ONLY Date Application Received: Received By: List Supporting Documents Received: Type of Application (Tick) All internet application s supporting documents must be posted to JGDM Information captured by: Signature Name: Date: Verified by:. Signature Name: Date:. Supplier No.:

9 MARK WITH X THE CATEGORY OF COMMODITIES / SERVICES YOU CAN SUPPLY CODE MAIN COMMODITY CODE MAIN COMMODITY CONSTRUCTION EQUIPMENT AND SUPPLIES Picture framing Air conditioning and temperature control equipment Printing Building equipment and accessories (cement mixers, scaffolding, trowels, levels, etc) Procurement services Building materials (bricks, cement, sand, painting, plastic, stone, steel, tiles, etc) Real estate services Ceiling boards, skirtings, etc Research services Construction machinery Security and safety services Doors and windows Site cleaning Electrical systems, lighting, components accessories and supplies Social Facilitating Flooring materials (carpets, tiles, etc) Storage Plumbing ware and materials Translation and interpreting services Roofing materials Transport services, general Sanitation ware and equipment Travel services Vehicle hire CONSTRUCTION SERVICES Vending services Burglar proofing and systems Concrete manufacture and works OFFICE AND FACILITIES EQUIPMENT AND SUPPLIES Construction-related transport Computer equipment, networks and software Demolition services Consumables Earthworks, drilling and landscaping Corporate gifts Electrical installation Domestic, industrial and cleaning equipment and supplies Fencing Electronic equipment, including audio-visual equipment General building work Fire protection equipment Glazing Flowers and plants Mechanical contracts Food and refreshments Metalwork Household furniture, appliances and goods Painting Office furniture and equipment Paving Office supplies and stationery Plumbing Printing, copying and photographic equipment and supplies Pre-cast concrete manufacture Pump installation MISCELLANEOUS GOODS AND SUPPLIES Road works Environmental cleansing equipment, goods and supplies Sewerage systems and construction Fire protection equipment, goods and supplies Water works and pipelines Garden tools Material and warehousing machinery, equipment and goods ELECTRICAL AND MECHANICAL EQUIPMENT, SERVICES AND SUPPLIES Measuring, testing and observation equipment Bearing supplies Protective clothing and uniforms Bolts, nuts and fasteners Security equipment, goods and services Electric cables Sports and recreational equipment and goods Electrical component supplies Electrical equipment repairs PROFESSIONAL SERVICES Hardware supplies Accounting, auditing and management services Lifting equipment Architectural services Mechanical seals and packing Consulting engineering-electrical Pipe and irrigation supplies Consulting engineering-environmental Power generation and distribution machinery and accessories Consulting engineering-other Pump spares Consulting engineering-project management Small tools Consulting engineering-roads and Storm water Transformer services Consulting engineering-sewerage systems Valves, couplings Consulting engineering-structures, Buildings, Bridges, etc Water meters, pipes, fittings, PVC, polyethylene, etcetera Consulting engineering-water systems Consulting engineering-geo-technical GENERAL SERVICES Consulting engineering-solid waste Accommodation and lodging Engineering services Advertising, communication, design, editorial, publication and marketing services Financial services Auctioneering services Land surveying Bookkeeping and accounting services Legal services-contracts Catering and refreshments Legal services-conveyancing Cleaning services Legal services-litigation Conferencing facilities and facilitation Legal services -other Contract administration Consulting engineering-mechanical

10 40090 Courier services Medical services Education and training Project management Environmental impact studies Quantity surveying Freight forwarding and cleaning services Town and regional planning General maintenance services Health care VEHICLE SUPPLY AND TRANSPORTATION SERVICES Horticulture Alarm and tracking systems Infrastructural maintenance Batteries Inspection services Engine overhauls Insurance Fuel, oils and lubrications IT, broadcasting and telecommunication services Hydraulics Interior decorating, refurbishment and upholstery Panel beating Land valuation services Radiator repairs Laundry and dry-cleaning services Spares and parts Locksmith services Towing services Mailing services Transmissions Management services Tyres and tubes Miscellaneous equipment and goods hiring Upholstery Personnel services Vehicle fleet management Pest control and removal services Vehicle supply Photographic and graphic design services Windscreens

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