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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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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
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
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
IDNumber: Designation:
Address:
OwnInterestinAnotherBusiness Y N SpecifyinSectionBelow Nationality: (AttachID)
% Ownership South African ? - Before 27/4/1994 ? Gender: Handicapped: Race % Time Spent
Method:
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Y N Y N M F Y N W B I C Other
(PleasecopythispageandaddtoApplicationifmorespaceisneeded)
LISTANYOWNERWHOHAVEANOWNERSHIPINTERESTINANOTHERBUSINESS
Name: Position:
NameofOtherBusiness:
TypeofBusiness: %Held:
Name:
Position:
NameofOtherBusiness:
TypeofBusiness: %Held:
Name: Position:
NameofOtherBusiness:
TypeofBusiness: %Held:
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
Less than 200 Less than R 39m Less than R 23m
ManufacturingMore than 200 More than R 51m More than R 19m
Less than 200 Less than R 51m Less than R 19m
Electricity, Gas and WaterMore than 200 More than R 51m More than R 19m
Less than 200 Less than R 51m Less than R 19m
ConstructionMore than 200 More than R 26m More than R 5m
Less than 200 Less than R 26m Less than R 5m
Retail, Motor Trade and Repair ServicesMore than 100 More than R 39m More than R 6m
Less than 100 Less than R 39m Less 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
Less than 100 Less than R 13m Less than R 3m
Transport, Storage and CommunicationsMore than 100 More than R 26m More than R 6
Less than 100 Less than R 26m Less than R 6m
Finance and Business ServicesMore than 100 More than R 26m More than R 5m
Less than 100 Less than R 26m Less than R 5m
Community, Social and Personal
Services
More than 100 More than R 13m More than R 6m
Less than 100 Less than R 13m Less 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
ReferenceNoContractValue
R
GovernmentDepartmentStartDate EndDate
Descriptionof
Contract
DepartmentalReference
(ContactNameandNumber)
ProvinceandMunicipalArea
of workdone
Supplied:
Goods Service
ReferenceNoContractValue
R
GovernmentDepartmentStartDate EndDate
DescriptionofContract
DepartmentalReference
(ContactName
and
Number)
ProvinceandMunicipalArea
of workdone
Supplied:
Goods Service
ReferenceNoContractValue
R
GovernmentDepartmentStartDate EndDate
DescriptionofContract
DepartmentalReference
(ContactNameandNumber)
ProvinceandMunicipalArea
of workdoneSupplied:
ReferenceNoContractValue
R
GovernmentDepartmentStartDate EndDate
DescriptionofContract
DepartmentalReference
(ContactNameandNumber)
ProvinceandMunicipalArea
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___________________________________________