Treasury Database Form

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APPLICATION FOR REGISTRATION (SCMO 1)PROVINCIAL SUPPLIERS DATABASE

EASTERN CAPE PROVINCE

THIS FORM MUST BE COMPLETED AND SUBMITTED TO:

BY HAND: SUPPLIERS DATABASE OFFICE(AT THE SUPPLY CHAIN MANAGEMENT OFFICE)SHOP NO. 5, TYAMZASHE BUILDING,

CNR. PHALO & INDEPENDENCE AVENUE, BHISHO.

BY POST: SUPPLIERS DATABASE OFFICE,C/O SUPPLY CHAIN MANAGEMENT OFFICE,PRIVATE BAG X0030, BHISHO, 5605.

ENQUIRIES:

Suppliers Database Office Tel: 040 609 5679

ForOfficialPurposesOnly:

NameofSupplier:

RegistrationNumber:

Documentsattached:

[ ] BusinessRegistration [ ] BusinessOrganogram [ ] Other

[ ] Cheque/BankVerificationLetter [ ] IDofOwners

[ ] SARSTaxClearanceCertificate [ ] Ratings/Endorsements/Certificates

Inputby:

Checked

by:

Approved

by:

Signature: Signature: Signature:

Date: Date: Date:

April2008


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EasternCapeProvincialTreasury

SCMO1 April2008 EasternCapeProvincialSupplierDatabaseApplicationForm Page2of12

IntroductionandGuidelines:

1. The SCMO 1 was specifically designed to provide for the registration of suppliers on the ProvincialSuppliers Database. In order to ensure that suppliers are considered to be legitimate suppliers, it isimperative that the following guidelines are adhered to.

2. Applicants must complete pages 3 to 11. where applicable. Failure by an applicant to provide ALLrelevant information and documents required will result in non-registration. If the informationrequired is not applicable to your business; clearly insert the symbols N/A in the appropriatespace If the space provided is left blank it will be regarded as information that is still outstandingand you WILL NOT be registered.

3. Applicants are advised that only an Original SCMO 1 formor PHOTOSTAT copies thereof will beprocessed. Any documents that have been retyped or redrafted will be disregarded and returned tothe applicant.

4. It is imperative that only an SCMO 1 form with an ORIGINAL Signatures be submitted.Applications with copied signatures will not be considered. All signatures to the document must becommissioned by an Author ized Commiss ioner of Oaths. Failure to do so will result in theapplicant not qualifying for registration.

5. A supplier registered on the Suppliers Database MUST notify the Supply Chain ManagementOffice of any changes to information provided in the initial SCMO 1. Failure to do so may result insuch a supplier being removed from the Suppliers Database and/or the cancellation ofcontracts awarded to the supplier, on the basis ofmisrepresentation.

6. Suppliers providing information incorrectly or fraudulently in their SCMO 1 will be restricted fromtendering and removed from the Suppliers Database, in addition to any other action the Provincemay institute against such a supplier. Furthermore, in the event of the Province being prejudicedfinancially, it reserves the right to take legal action against the supplier.

7. Electronic forms are available on the website: www.ectreasury.gov.za

Instructions for filling out relevant sections of this form

All relevant sections of this form must be completed by prospective suppliers only in black ink;

Corrections can be made by drawing a line across the incorrect statement, writing in the correctdetails above the same, and subsequently endorsing the entry with the applicants signature.

Please select applicable boxes by making a tick (), only make one selection unless otherwisespecified; and indicate those which do not apply by writing N/A (not applicable); If the space provided is not sufficient, please note a reference to and include an annexure paper

hereto, which complies with the specified format and numbering in this form, showing the additionaldetails.

With regard to an existing supplierwith information to be updated, please provide your SupplierName and Supplier Number below, then only fill in the information to be updated and submit theentire form.

Tick

()Checklis t: All applicable documents listed below must be attached to all

registration forms.

Certified copies of Business Registration Certificate where applicable.Valid SARS Tax Clearance Certificate (always) and VAT Registration Certificate where

applicable.

An original cancelled cheque and bank verification letter (always)

Business organogram showing holding company, subsidiary companies, operating divisions,

etc.where applicable.

Any other relevant independent agency ratings, industry endorsements, accreditation

certificates where applicable, such as CIDB, PSIRA and NHBRC).


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SUPPLIER REGISTRATION FORM

New

Supplier

Reregistration ExistingSupplier

InformationUpdate

ExistingSupplier

RegistrationNumber

A1 BASICSUPPLIERINFORMATION

RegisteredBusiness

NameofSupplier

TradingNameofSupplier

RegistrationNumber

(CIPRO,etc)

YearofRegistration YearsinOperation

BusinessType

(Tickbox)

PublicCompany Ltd AttachCertifiedcopyofIncorporation(CM3)

PrivateCompany(Pty)Ltd AttachCertifiedcopyofIncorporation(CM3)

CloseCorporation CC AttachCertifiedcopyof(CK1&CK2)

SoleProprietor AttachCertifiedcopyofIDDocument

Partnership

Attach

Certified

copy

of

Partnership

Agreement

Trust AttachCertifiedcopyofTrustDocument

Cooperative AttachCertifiedcopyofCoOpRegistration

CommunityBasedOrganization(CBO) AttachCertifiedcopiesofallMembersIDs

VoluntaryAssociations AttachCertifiedcopyofConstitution

ForeignCompany AttachCertifiedcopyofIncorporation

BusinessSector

Industry

Classification

(Tickbox)

Catering,

Accommodationand

other Trade

Retail,MotorTradeand

RepairServices

Community,Social&

PersonalServices

MiningandQuarryingTransport,Storageand

Communications

FinanceandBusiness

Services

Construction

Agriculture

Manufacturing

Electricity,Gas&

WaterWholesaleTrade,CommercialAgentsandAlliedServices

Supplier

Classification

(Tickallthatapply)

ISORated Manufacturer Distributer

Sales Services Repair

Importer Exporter

A2 CONTACTDETAILS

PleaseindicateyourProvincebycirclingtheabbreviationbelow: EC EasternCape,GT Gauteng,KZN KwaZuluNatal,LP LimpopoFreeState,MPMpumalanga,NP NorthernProvince, NC NorthernCape,LP WCWesternCape

Registered

POSTAL

Address:

(CircleProvincebelow)PO

Box/Bag

Suburb/Town

EC,WC,NC,GT,MP,LP,KZN,NP,FS City Postcode

HeadOfficePHYSICAL Address:PleaseindicateCountryifnot RSA

____________________________(CircleProvincebelow)

Building Floor

Street

Suburb/Town

EC,WC,NC,GT,MP,LP,KZN,NP,FS City Postcode

Municipal MunicipalLocal


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District

HeadOfficeContactDetails(forpayments):

(CircleTitlebelow)

Mr. / Mrs. / Ms. / Miss.

Other_________ (Specify)

Person:

Designation:

Telephone: Fax:

Cell:

Email:

Website

Address:

BranchOfficePhysicalAddress:

(CircleProvincebelow)Street

Suburb/Town

EC,WC,NC,GT,MPLP,KZN,NP,FS City Postcode

Municipal

DistrictMunicipalLocal

AlternativeContactDetails:

(CircleTitlebelow)

Mr. / Mrs. / Ms. / Miss.

Other_________ (Specify)

Person:

Designation:

Telephone: Fax:

Cell:

Email:

(SpecifytheOffice) Locatedat:

(PleasecopythispageandaddtoApplicationifmorespaceisneededforAdditionalBranchOffices)

A3 ACCREDITATION/CERTIFICATION(CIDB,NHBRC,PSIRA,etc.) (N.B. AttachacopyofAccreditations

/AddPagesformorespace)

DocumentNoofAccreditation: IssueDate:

IssuingOrganization: ExpiryDate:

IssuingOrganization

RegistrationNumber:

Reference/

MemberNo:

NameofCertificate: Grading

StatusofCertification:

TypeofCertification: MembershipPeriod:

A4 BANKINGINFORMATION (N.B. AttachBankVerificationletterfromyourBank tothisapplication)

BankDetailsforthisoffice:

OfficialBankStamp

AFFIXOFFICIAL

BANK

STAMPHERE

(Attachacopyororiginalbank

statementnotolderthan60

days).

BankName:

BankLocation:

BranchName:

BranchCode:

AccountHolder:

AccountNumber:

AccountType:(TickOne)

Cheque Transmission NotinUse

Savings Subscription Bond

BankOfficialName: Designation: Signature:

PreferredPaymentMethod:

DefaultPaymentTerms: InvoiceDelivery


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A5 TAXINFORMATION (N.B. AttachavalidTaxClearanceCertificatetothisapplication)

SARSTaxReferenceNumber(Insertpersonaltaxnumberifaonepersonbusiness(SoleProprietor)or

PersonalIncomeTaxnumbersofallpartnersinapartnership.)

VATRegistrationNumber

RSCRegistrationNumber

SuppliersSARSOfficeandTelephone

contactnumberwheretaxfileisheld

B1 Proprietors/Shareholders/Partners/SoleProprietor/Trustees/Beneficiaries(Owners)

List all persons who are OWNERS (Proprietors/Shareholder/Partners/Sole

Proprietors/Trustees/Beneficiaries)inthebusinessorTrustbeingregistered

and indicate their involvement in the management/operations of the

business/Trust.

IN THE CASE OF HANDICAPPED, PROOF OF DISABILITY PROVIDED BY A

RECOGNIZEDRELATEDINSTITUTIONMUSTBEATTACHED

If insufficientspace,NB:kindlyattachacopy/copiesofthe followingpage

tothisSCMO1form,signedbythesamepersonwhosignsonbehalfofthe

business/Trust

N.B. %Ownershipshouldaddupto100%

SACitizenbefore27/4/1994

Handicapped=Yes attachproof.

RaceWhite,Black,Indian,Coloured,Other

%Time

spent

in

the

daily

activities

of

this

business

OwnersInformation (Circlechoiceorfillintherequiredinformation.) RegardingOwnersandTrusts

FullName: Trustee?Y N

Beneficiary?Y N

IDNumber: Designation:

Address:

OwnInterestinAnotherBusiness Y N SpecifyinSectionBelow Nationality: (AttachID)

% Ownership South African ? - Before 27/4/1994 ? Gender: Handicapped: Race % Time Spent

Y N Y N M F Y N W B I C Other

FullName:

Trustee?

Y N

Beneficiary?

Y

N


Address:





Beneficiary?Y N


Address:

OwnInterestinAnotherBusiness Y N SpecifyinSectionBelow Nationality: (AttachID))




Beneficiary?Y N


Address:



Method:


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(PleasecopythispageandaddtoApplicationifmorespaceisneeded)

LISTANYOWNERWHOHAVEANOWNERSHIPINTERESTINANOTHERBUSINESS

Name: Position:

NameofOtherBusiness:

TypeofBusiness: %Held:

Name:

Position:



Name: Position:



B2 DECLARATIONOFCONFLICTOFINTERESTBYPROSPECTIVESUPPLIER

AreanyofyourOwnersorSenior/ExecutiveManagementcurrentGovernmentOfficials.Ifyes,specifybelow Yes No

DoanyofyourDirectors/Ownershaveanyprevious/currentassociationwithGovernment?Ifso,please

indicatebydeclaringsuchinterest/associationinthespacebelow Yes No

B3 FINANCIALCLAIMSAGAINSTPROSPECTIVESUPPLIER

Haveyourorganization/parentcompany/formercompanywiththesameprincipalsever beenliquidated?

IfYespleasegivedetailsbelow.Yes No

DateofLiquidation

HastheLiquidationbeenresolved? DateResolved:

WhowasappointedasTrustee?

WhatwasthereasonforLiquidation?

Haveyourorganization/parentcompany/formercompanywiththesameprincipalseverbeenrestricted

forGovernmentTenders?IfYespleasegivedetailsbelow.Yes No

WhendidRestrictioncommenceanduntilwhatdate? From: To:

Whichinstitutioninvokedtherestriction?

Whatwasthereasonfortherestriction?

B4 LITIGATION/JUDGMENTHISTORY

Nature

of

Claim

/

Judgment

Start

Date

CauseofDispute

PartiesInvolvedinDispute

StatusofClaim EndDate

ClaimFinancialImplications

NatureofClaim/Judgment StartDate

CauseofDispute

PartiesInvolvedinDispute

StatusofClaim ` EndDate


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ClaimFinancialImplications

(PleasecopythispageandaddtoApplicationifmorespaceisneeded)

PreviousBusinessInformation

Didyourbusinessexistunderapreviousname? Yes No

IfYeswhatpreviousname(s)? Year:

Year:

Whywasthenamechanged?

PreviousSuppliersDatabasenumber?

Owners,partners,membersorshareholdersnowderegistered:

Name Title IDNumber

BusinessInformation:

ThefollowingtablemustbecompletedtoestablishwhetherabusinesscanbeclassifiedasanSMMEintermsoftheNationalSmallBusinessAct102of1996.SelecttheSectorandticktheappropriateblocksinColumn2,3and4.

Column 1 Column2(tickapplicable) Column3(tickapplicable) Column4(tick applicable)

Sector or subsectors in accordance

with the Standard Industrial Council

Total full time equivalent of paid

employees

Total annual turnover Total Gross Asset Value

(fixed property excluded)

AgricultureMore than 100 More than R 5m More than R 5m

Less than 100 Less than R 5m Less than R 5m

Mining and QuarryingMore than 200 More than R 39m More than R 23m


ManufacturingMore than 200 More than R 51m More than R 19m


Electricity, Gas and WaterMore than 200 More than R 51m More than R 19m


ConstructionMore than 200 More than R 26m More than R 5m


Retail, Motor Trade and Repair ServicesMore than 100 More than R 39m More than R 6m


Wholesale Trade, Commercial Agentsand Allied Services

More than 100 More than R 64m More than R 10mLess than 100 Less than R 64m Less than R 10m

Catering, Accommodation & other tradeMore than 100 More than R 13m More than R 3m


Transport, Storage and CommunicationsMore than 100 More than R 26m More than R 6


Finance and Business ServicesMore than 100 More than R 26m More than R 5m


Community, Social and Personal

Services

More than 100 More than R 13m More than R 6m



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D GOODSANDSERVICESSUPPLIEDBYYOURBUSINESS

In order to assist with the classification process, a short summary of your core business and key products and services must be provided.Our

Core

Business

Is:

Goods orService:

Description:

(Include Brand)

Unit ofMeasure:(hr/day/ea/box/doz/etc.)

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S

G S


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G S

G S

G S

(Please copy this page and add to Application if more space is needed)

E CURRENTORPREVIOUSSUPPLYCONTRACTSWITHGOVERNMENTDEPARTMENTS

ReferenceNoContractValue

R

GovernmentDepartmentStart

Date

End

Date

DescriptionofContract

DepartmentalReference

(ContactNameandNumber)

ProvinceandMunicipalArea

of workdone

Supplied:

Goods Service


R

GovernmentDepartmentStartDate EndDate

Descriptionof

Contract




of workdone

Supplied:

Goods Service


R




(ContactName

and

Number)


of workdone

Supplied:

Goods Service


R






of workdoneSupplied:


R






of workdone

Supplied:

Goods Service


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OTHERRELEVANTADDITIONALDETAILS

INDUSTRIALSECTOR/SYOURBUSINESSPROVIDESSERVICES/GOODSFOR (TickallthatApply)

Tick IndustrialSectorDescription UNSPCCode Tick IndustrialSectorDescription UNSPCCode

Apparel&Luggage&PersonalCareProducts 53101501 LivePlant&AnimalMaterial&Accessories&

Supplies10101501

Building&Construction&MaintenanceServices 72101501 Management&BusinessProfessionals&

AdministrativeServices80101501

Building&ConstructionMachinery&

Accessories22101501 ManufacturingComponents&Supplies 31101501

ChemicalsincludingBioChemicals&Gas

Materials12131501

MaterialHandling&Conditioning&Storage

Machinery&TheirAccessories&Supplies24101501

CleaningEquipment&Supplies 47101501 MedicalEquipment&Accessories&Supplies 42121501

Commercial&Military&PrivateVehicles&

TheirAccessories&Components25101501

Mineral&Textile&InediblePlant&Animal

Materials11101501

Defense&LawEnforcement&Security&Safety

Equipment&Supplies46101501 Mining&Oil&GasServices 71101501

Distribution&ConditioningSystems&

Equipment&Components40101501 Mining&WellDrillingMachinery&Accessories 20101501

DomesticAppliances&Supplies&Consumer

ElectronicProducts52101501

MusicalInstruments&Games&Toys&Arts&

Crafts&EducationalEquipment&Materials&

Accessories&Supplies

60101001

Drugs&PharmaceuticalProducts 51101501 NationalDefense&PublicOrder&Security&Safety

Services92101501

Editorial&Design&Graphic&FineArts

Services82101501 OfficeEquipment&Accessories&Supplies 44101501

Educational&TrainingServices 86101501 Organizations&Clubs 94101501

ElectricalSystems&Lighting&Components&

Accessories&Supplies39101601 PaperMaterials&Products 14101501

ElectronicComponents&Supplies 32101501 Personal&DomesticServices 91101501

Engineering&Research&TechnologyBased

Services81101501 Politics&CivicAffairsServices 93101501

EnvironmentalServices 77101501 PowerGeneration&DistributionMachinery&

Accessories26101501

Farming&Fishing&Forestry&Wildlife

ContractingServices70101501

Printing&Photographic&Audio&Visual

Equipment&Supplies45101501

Farming&Fishing&Forestry&Wildlife

Machinery&Accessories21101501 PublicUtilities&PublicSectorRelatedServices 83101501

Financial&InsuranceServices 84101501 PublishedProducts 55101501

Food&Beverage&TobaccoProducts 50101538 Resin&Rosin&Rubber&Foam&Film&

ElastomericMaterials13101501

Fuels&FuelAdditives&Lubricants&Anti

CorrosiveMaterials15101501 ServiceIndustryMachinery&Equipment&Supplies 48101501

Furniture&Furnishings 56101501 Sports&RecreationalEquipment&Supplies&

Accessories49101601

HealthcareServices 85101501 Structures&Building&Construction&

ManufacturingComponents&Supplies30101501

IndustrialCleaningServices 76101501 Timepieces&Jewelry&GemstoneProducts 54101501

IndustrialManufacturing&Processing

Machinery&Accessories23101501 Tools&GeneralMachinery 27111501


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IndustrialProduction&ManufacturingServices 73101501 Transportation&Storage&MailServices 78101501

InformationTechnologyBroadcasting&

Telecommunications43191501 Travel&Food&Lodging&EntertainmentServices 90101501

Laboratory&Measuring&Observing&Testing

Equipment41101502

F2 DECLARATION

VERIFICATIONOFINFORMATIONSUPPLIEDINTHISSCMO1FORM,INCLUDINGINFORMATIONSUPPLIED

RELATINGTOPREFERENCESTHATTHEAPPLICANT(BUSINESS)MAYAPPLYFOR:

I/we,theundersigned,warrantsthathe/sheisdulyauthorizedtodosoonbehalfofthesupplier,

certifiesthattheinformationsuppliedintermsofthisdocument(SCMO1)includingtheannexure/s

withadditionalinformation,iscorrectandaccurateandI/weacknowledgethat:

Thesupplier/applicant,whichisthesignatoryhereto,willberequiredtofurnishdocumentaryproofofthe

informationrelatingtopreferences,ifrequiredtodoso.

IftheinformationsuppliedinthisSCMO1formisfoundtobeincorrectthentheProvincemay,inaddition

toanyremediesitmayhave:

a. Disqualify

the

supplier/applicant

for

a

particular

bid/contract/project

it

may

be

considered

for,

orwhichhadbeenawardedtothesupplier/applicant;

b. Recoverfromthesupplier/applicantallcosts,lossesordamagesincurredorsustainedbytheProvince

asaresultofbreachofthecontract;

c. Cancel the contract and claim any damages which the Province may suffer by having to make lessfavorablearrangementsaftersuchcancellation;and/or

d. DeregisterthesupplierregisteredontheSupplierDatabase

SIGNEDBEFORETHECOMMISSIONEROFOATHSONTHIS______DAYOF___________________________

20________.

SUPPLIERSNAME:_______________________________________________________________________

SIGNATORYNAMEINBLOCKLETTERS_______________________________________________________

SIGNATUREOFAUTHORIZEDREPRESENTATIVE________________________________________________

SIGNATORYIDNUMBER____________________________________

SIGNATORYCAPACITY___________________________________________________________________

Signed and affirmed to, before me at_______________________________on this___________ day of

_________________________ 20____,bythedeponentwhohasacknowledgedthathe/sheknowsand

understandsthecontentsofthisdocument,andhe/shehasacknowledgedthathe/shehasnoobjectionto

affirmingthathe/sheregardstheaffirmationtobebindingonhis/herconscience.

___________________________ __________________________________________________

CommissionerofOathsSignature CommissionerofOathsFullName


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BusinessAddress_______________________________________________________________________

Capacity_______________________________________

Area___________________________________________