- 1 - SUPPLIER DECLARATION FORM

- 1 - SUPPLIER DECLARATION FORM

- 2 - Health Professions Council of South Africa This form must be completed and submitted with proposal: Health Professions Council of South Africa P O Box 205 PRETORIA 0001 553 Madiba (previously known as Vermeulen) Street Arcadia PRETORIA 0007 Please complete the form fully and use a black pen. Illegible or incomplete forms will be rejected. Direct enquiries to Procurement Officer Tel 012 338 9302 Email: fredax@hpcsa.co.za PLEASE KEEP COPIES OF REGISTRATION FORM AND ALL DOCUMENTATION SUBMITTED FOR YOUR RECORDS AS NO COPIES WILL BE MADE BY THE COUNCIL

- 3 - TYPE OF BUSINESS Indicate the sector by ticking the appropriate block in column TYPE OF SERVICE YES NO 1 Recording and Transcription Services (minimum of 5 appropriate years experience) NB: Applicants should have experience/expertise in the following fields: Accurate recording and transcription of hearings and meetings and Transcription services in either the Magistrate or the High Courts 2 Translation services (minimum of 5 years appropriate experience) 3 Interpretation and sign language services (minimum of 3 years appropriate experience) 4 Building Maintenance and Repairs (minimum of 3 years appropriate experience and proof of registration and qualification) Waterproofing Painting Renovations Tiling Carpeting General Building 5 Plumbing Services (minimum of 3 years appropriate experience and proof of registration and qualification)) 6 Courier Services (minimum of 3 years appropriate experience) Same Day Express Same day Delivery to Main Centres Dawn Express by 09h00 to Main Centres Overnight Express by 10h30 Intra City (Including JNB-PRY-JNB) Next Day Service 24-48 hours Regional Areas Economy Freight International Other 7 Stationery, Copy Paper and HP Laser Jet Cartridges (minimum of 2 years appropriate experience) NB:

- 4 - Quotations are to be provided within 2 working days of request Delivery is expected within but not later than 48 hours of receiving an official order Quotations will be obtained on a rotational basis if and when stationery and/or cartridges are required Requesting a quotation does not automatically qualify the supplier 8 Florist (minimum of 2 years appropriate experience) in providing flowers/flower arrangements to the HPCSA 9 Shredding of Paper (minimum of 2 years appropriate experience in providing shred it services on site through use of mechanical shredding devices (the document destruction process ) 10 Office Furniture (minimum of 3 years appropriate experience) Human Resources Services 11 Temporary Employment Agencies (minimum of 5 years appropriate experience) 12 Recruitment Agencies (minimum of 2 to 3 years appropriate experience) 13 Recruitment Consultants for placement of advertisements in the national print and electronic media. Do response handling where required. (minimum of 2 years appropriate experience) 14 Labour Relations Consultants and Labour Law Practitioner to provide expert labour relations and labour law consultancy services, including chairing of disciplinary hearings, assist with investigations of alleged misconducts, representing the organization at CCMA and Labour Court, chairing incapacity investigations. (minimum of 5 years appropriate experience and knowledge of CCMA and Labour Court Rules) 15 Psychometrics Service Providers/Consultants (HPCSA Registration) 16 Staff Training (minimum of 3 years appropriate experience) Public Relations Services (minimum of 5 years appropriate experience in the under mentioned) 17 Promotional Items/Gifts 18 Event Management 19 Magazines 20 Electronic Newsletters/Bulletins 21 Printing Bulletins/Newsletters

- 5-22 Crew news 23 Newspaper advertisements 24 Supply/delivery of News papers IT Services (minimum of 5 years appropriate experience in the under mentioned) 25 HP Computers and computer Peripherals 26 Network switches 27 License Renewals for Microsoft & Symantec 28 Network routers 29 EMC or Dell storage area network solution servers 30 IP Telephone office devices Where applicable under mentioned documents must be attached with proposals Please tick box Y N NA BEE/B-BBEE Status A valid B-BBEE Verification Certificate issued by a Registered Auditors approved by the Independent Regulatory Board of Auditors [IRBA) or South African National Accreditation System (SANAS) CIDB Certificate (certified) Other applicable legislated certificates (Certified) Valid Workman s compensation certificate (certified) Company registration document (certified) Proof of ownership/ shareholder certificate (certified) Valid Tax clearance certificate (original) Proof of banking document Comprehensive company profile Liability Insurance

- 6 - BUSINESS PARTICULARS Name of Business Physical address City Province Postal address (if not same as above) City Province Telephone Fax no Cell no Email address Web page address

- 7 - Contact person for correspondence address Name Surname Sales Department Contact name SALES AND ACCOUNTS DEPARTMENTS Telephone Fax Email address Cell no Accounts Department Banking institution name FINANCIAL DETAILS (BANKING) Branch Town/City Banking account number Account type Account holder s name NB: Documentary proof of banking institution must be supplied (cancelled cheque/ bank statement)

- 8 - HDI INFORMATION Explanation of abbreviations used in the following tables: Capacity HDI status Director D HDI H Partner P Women W Member M Disabled D Priority Other R O Proof of disability provided by a recognized institution in the case of handicapped persons must be supplied. NB: certified copy of shareholder certificates or proof of ownership must be supplied Complete the following for the shareholders who are actively involved in the management and daily business operation of the business. First name Surname Identification number Capacity D P M R O M F (sex) HDI status H W D Disabled (permanent impairment of a physical, intellectual or sensory function resulting in restricted or lack of ability to perform in a manner considered in a manner considered normal for a human being) Are you actively involved in the management and daily business operations of the business? (please provide a written breakdown e.g company profile)

- 9 - First name Surname Identification number Capacity D P M R O M F (sex) HDI status H W D Disabled (permanent impairment of a physical, intellectual or sensory function resulting in restricted or lack of ability to perform in a manner considered in a manner considered normal for a human being) Are you actively involved in the management and daily business operations of the business? (Please provide a written breakdown e.g company profile) First name Surname Identification number Capacity D P M R O M F (sex) HDI status H W D Disabled (permanent impairment of a physical, intellectual or sensory function resulting in restricted or lack of ability to perform in a manner considered in a manner considered normal for a human being) Are you actively involved in the management and daily business operations of the business? (Please provide a written breakdown e.g company profile)

- 10 - CONTACTABLE REFERENCES Please supply a list containing the names, telephone numbers and client relationship of a minimum of three contactable references Contact person Contact number Client Relationship Contact person Contact number Client Relationship Contact person Contact number Client Relationship PREVIOUS CONTRACT OR TENDERING EXPERIENCE (Mark with X) Do you have any previous contract work or tendering experience? Yes No If yes, please complete the table below. List the last two contracts awarded to you or previous experience with other businesses related to this of work or supply Employer/ Department

- 11 - Contact person Contact number Estimated contract value in rands Year awarded Proof documents attached Yes NO Did your business exist under a previous name? If yes, what name did it trade under? Previous business registration number CERTIFICATION OF CORRECTNESS OF INFORMATION SUPPLIED IN THIS DOCUMENT 1. The information supplied is correct. 2. All copies of relevant information are attached. 3. Take note that payment will be effected 30 days after delivery was effected if delivered with an original invoice.

- 12 - PERSONAL INFORMATION IN BLOCK LETTERS Name Surname Telephone Capacity On behalf of the (supplier s Name) Signed and sworn to before me at on this the day of 2014 by the Deponent, who has acknowledged that he / she knows and that understands the contents of this Affidavit, that it is true and correct to the best of his /her knowledge and that he /she has no objection to taking the prescribed oath, and that the prescribed oath will be binding on his/her conscience. Commissioner of Oath Signature: Applicant on behalf of supplier

- 13 - Authorization for electronic transfer of funds (EFT) PLEASE COMPLETE IN BLOCK LETTERS Company name/surname Company Account Holder Address Telephone Fax Mobile Email Bank Branch Bank Account Branch number Type of Account Cheque Savings Transmission Date Signature For use of bank (in cases where a cancelled cheque is not attached) Above information checked and confirmed Signature: Bank Stamp