APPLICATION FORM

APPLICATION TO BE LISTED ON THE

SOUTH AFRICAN HUMAN RIGHTS COMMISSION’S

SUPPLIER DATABASE

FOR THE SUPPLY OF GOODS AND SERVICES

1.COMPANY/PERSONAL DETAILS

Legal name of company:
Trading name of company:
Tax Number:
Vat Number:
Company Registration Number:
CC Registration:
Title:
Initials:
First Name:
Surname:

2. ADDRESS DETAIL

Postal address of company

Physical address of company

3. CONTACT DETAILS

Business

Home

Fax

Cell

Email Address

Contact Person

Company website address

4. CORE BUSINESS

(Please add a code from the category listing below)

5. NAMES OF ALL OWNERS, DIRECTORS OR MEMBERS AND THEIR RESPECTIVE DESIGNATIONS

Names Of Owners and Members / Designation

6. SPECIFIC EXPERTISE VESTED IN COMPANY

7. COMPOSITION OF COMPANY (RACE, GENDER, DISABILITY)

Race / Gender / Disability

8.ANNUAL TURNOVER (AMOUNT IN RANDS)

9.LIST OF SERVICES OFFERED

10.MONETARY VALUE OF CONTRACTS – MAXIMUM QUANTITIES THAT CAN BE SUPPLIED AND FREQUENCY OF DELIVERY OR ANY OTHER INFORMATION

Monetary Value / Maximum Quantities

1

11.LIST ALL SHAREHOLDERS BY NAME, POSITION, IDENTITY NUMBER, CITIZENSHIP, HDI STATUS AND OWNERSHIP (PLEASE COMPLETE TABLE BELOW)

HDI / Status
Name / Date/Position / ID / Date RSA / No / % of
Business/Enterprise Owned
Occupied in / Number / Citizenship / Franchise
Enterprise / obtained / Prior to / Woman / Disabled
Elections

1

12.DECLARATION OF APPLICANTS’ PAST SUPPLY CHAIN MANAGEMENT PRACTICES

a. / Is the company or any of its directors listed on the National Treasury’s database as companies or persons prohibited from doing business with the public sector?
If so furnish particulars: / YES / NO
b. / Is the company 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 (No 12 of 2004)?
If so furnish particulars: / YES / NO
c. / Was the company 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: / YES / NO
d. / 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?
If so furnish particulars: / YES / NO
  1. BANKING DETAILS

Name of Account Holder
Name of Bank
Branch Name
Branch Code
Account Number
Account type
  1. THE FOLLOWING SUPPORTING DOCUMENTS ARE TO BE SUBMITTED TOGETHER WITH THIS APPLICATION FORM
  • An original and valid tax clearance certificate or proof of tax exemption.
  • Permission that the financial position of the supplier’s service providers and the ability to manufacture or to supply goods or to render a service may be examined before its offer is considered for acceptance.
  • Company registration certificate with shareholder percentages
  • Reference letters (at least two)
  • The completed banking details form signed and stamped by the company’s banking institution
  • Company profile
  • BBBEE verification certificate

a) Procurement and Administration:
  • Office cleaning (PA1)
  • Printing (PA2)
  • Travel services (PA3)
  • Courier services (PA4)
  • Stationery (PA5)
  • Catering (PA6)
  • Office maintenance (PA7)
  • Office furniture (PA8)
  • Security Services (PA9)
  • Conference facilities (PA10)
  • Off-site Corporate storage facilities (PA11)
  • Audit services (PA12)
  • Legal services (PA 13)
  • Strategic planning (PA14)
  • Other related services (PA15)
/ b) Human Resources:
  • Recruitment and placement (HR1)
  • Job evaluation consultants (HR2)
  • Legal compliance consultants (HR3)
  • Salary benchmarks and surveys (HR4)
  • Dispute resolution experts, qualified mediators and arbitrators (HR5)
  • Business processes specialists (HR6)
  • Organisational development (HR7)
  • Other related services (HR8)
/ c) Marketing and Public Relations:
  • Advertising (MPR1)
  • Corporate gifts (MPR2)
  • Corporate Clothing (MPR3)
  • Special events/functions (MPR4)
  • Event management (MPR5)
  • Media services (MPR6)
  • Design and layout (MPR7)
  • Video and related services (MPR8)
  • Editorial services (MPR9)
  • Other related services (MPR10)

d) Information Technology & Communications:
  • Telephone Services (IT1)
  • Telephone/PABX maintenance (IT2)
  • IT software & hardware suppliers (IT3)
  • IT maintenance (IT4)
  • Data warehousing (IT5)
  • Website development and maintenance (IT6)
  • Other related services (IT7)
/ e) Research & Analysis:
  • Economic and social research (RA1)
  • Labour Market analysis (RA2)
  • Monitoring and evaluation (RA3)
  • Sector specific research (RA4)
  • Other related services (RA5)
/ f) Training Provision:
  • Learnership Development Providers (TP1)
  • Resource and Materials Developers (TP2)
  • Curriculum and Learning Programme Designers (TP3)
  • Assessors and moderators (TP4)
  • Training providers in all sectors across existing qualifications and scarce skills (TP5)
  • Financial Management (PFMA & Supply Chain Management) (TP6)
  • Other related services (TP7)

(Please tick the appropriate category/ies for your application)
14. CERTIFICATION

I/We the undersigned, who warrant/s that he/she/we is/are duly authorized to do so on behalf of the company, certify that the percentage ownership/shareholders claimed are actively involved in the day to day management of the enterprise and I/we acknowledge that:

  1. The information furnished on this form is true and correct
  2. In the event of a contract being awarded as a result of the above mentioned information, the contractor may be required to furnish documentary proof to the satisfaction of the South African Human Rights Commission that the information is correct.

c. I/we accept that, in addition to cancellation of a contract, action may be taken against me/us should the information furnished prove to be false.

SIGNATURE: ______DATE:______

Name in block letters:______

SIGNATURE: ______DATE:______

Name in block letters:______

SIGNATURE: ______DATE:______

Name in block letters:______

SIGNATURE: ______DATE:______

Name in block letters:______

WITNESSES:

  1. …………………………………………………..
  1. ……………………………………………………

1