1 of 39

Enquiries:
E-mail:
Tel No:

SUPPLIER DATABASE REGISTRATION
FOR 2010 TO 2011 FINANCIAL YEAR



NAME OF SERVICE PROVIDER: _________________________________
(To be completed by supplier)

FOR OFFICIAL PURPOSES


Name of Evaluator from SCM: ____________________________________

Persal No: ______________ Signature: ____________________

Date:

Entity Maintenance No: ________________

Captured by: ________________ Persal No: ______________

Signature: ________________ Date: ______________


APPLICATION ACCEPTED

APPLICATION
REJECTED

DoJ & CD
Supplier Number




Verified & Captured on Su pplier Database by : ________________

Persal No: ______________ Signature: ____________________

Date:
Hlosi Holdings (Pty) LTD
2 of 39
SUPPLIER DATABASE REGISTRATION FOR 2010 TO 2011 FINANCIAL YEAR

The Department of Justice and Constitutional Development (DoJ&CD) is an outwardly
focused, customer-centered government department mandated to uphold and protect the
Constitution and Rule of Law in the interest of a safer and more secure South Africa. DoJ
& CD, pursuant to the provisions of the Public Finance Management Act (PFMA), Act 1
of 1999) read with CIPRO Supply Chain Management Policy invites service providers to
register on DoJ & CDs database of suppliers/services as official vendors and suppliers
for the 2010 to 2011 Financial Year.

Suppliers and service providers currently registered as vendors on the DoJ & CD
database should also re-apply for considerations to be re-registered on the DoJ & CD
vendor/supplier database. Enterprises owned by HDIs (Historically disadvantaged
Individuals), Women, Youth, People with Disabilities and BEES (Black Economic
Empowerment) are encouraged to apply.

A list of commodities requirements are enlisted in the supplier database application form.
Prospective suppliers/service providers may apply to be enlisted on the supplier
database for a maximum of five (5) commodities specific as per their principle business,
other than those suppliers on SITA transversal contracts. Failure to comply with this
condition will invalidate the applications and would not be evaluated further. Supplier
Database registration forms are obtainable from: Website: www.justice.gov.za

Physical Address: Momentum Centre Postal address: Private Bag X81
329 Pretorius Street Pretoria
Pretoria 0001
0001

Enquiries should be forwarded to:

Tel No: E-mail Address Fax No.

N.Skosana 012 357 8583 nskosana@justice.gov.za 086 640 3113

I. Thusi 012 357 8291 ithusi@justice.gov.za 086 688 5470

M. Karabo 012 357 8198 kmasilo@justice.gov.za 086 642 3759

M.S.Bassier 012 315 4545 Sbassier@justice.gov.za 086 641 2053


Closing date: 31 October 2010 at 11:00

Completed registration forms may be hand delivered or posted to the above mentioned
postal address on or before closing date and time for attention: The Director: Supply
Chain Management (DoJ & CD)









3 of 39










SUPPLIER REGISTRATION FORM


IMPORTANT NOTES
Please read carefully before completion of registration form

To be completed by all vendors seeking registration as an approved supplier;
The supplier registration form must be completed in full and be signed, and forwarded to the
National Department of Justice and Constitutional Development at Pretoria with all supporting
documentation ;
A company profile which also addresses the evaluation criteria set out in this document must
accompany the registration form but will not be accepted as substitute for the application form
all fields on application form MUST be completed by applicant;
Successful applicants will be contacted via fax and/or email and must therefore submit an
operating fax number and/or email address; failure to comply will result in excluding the
supplier from the data base;
Only successful suppliers will be notified in writing on their application been accepted;
Supplier must comply with all the registration-criteria for registration to be finalized - failure to
do so will result in the application being declined.
All shareholders/ Directors/ Members and in case of one-man concern, please furnish identity number plus
copy of identity documents

Research & Development contact details:
Telephone: 012 357 8198 / 012 315 1682
Fax number: 086 687 7698
Email: jypresearchanddevelopment@justice.gov.za

1. SUPPLIER DETAILS(All fields are mandatory)

Details:
Company Name:
(Orders will be issued In this
name )


Trading Name:
Registration Number:

ID number:
Hlosi Holdings (Pty) LTD
Hlosi Suppliers & Logistics
2011/105437/07
7310015403088
4 of 39


VAT Number:

Income Tax Number

Telephone Number:

Fax Number:

Website Address:

Postal Address:



Physical Address:



Banking Details
Bank Name:

Branch Name:

Account Type:

Branch Code:

Account Number:

Main Contact:
Name:

Surname:

Position:

Telephone Number:

Facsimile Number:

Cellular Number:

E-mail Address:

9102377187
086 2355 983
306 Waverley Court
54 Margaret Mncadi Avenue
Durban
306 Waverley Court
54 Margaret Mncadi Avenue
Durban
4001
First National Bank
Natal Branch
Cheque
62325657057
Mandla
Mjwara
Executive Director
086 2355 986
0729230534
mandla.mjwa@gmail.com
5 of 39


2. SUPPLIER GROUPING DETAILS: (Please mark with an X the relevant box)
Public Company (Ltd)


(Attach a Certified copy of Incorporation (CM3)


Private Company (Pty) Ltd


(Attach a Certified copy of Incorporation (CM3))


Closed Corporation (cc)

(Attach a Certified copy of (CK1 & CK2))


Sole Proprietor


(Attach a Certified copy of ID Document)


Partnership


(Attach a Certified copy of Partnership Agreement)


Trust


(Attach a Certified copy of Trust Document)


Foreign Company


(Attach a Certified copy of Incorporation)


Joint Venture


(Attach a Certified copy of all Members ID Documents
and joint venture agreement signed by all parties)

Consortium


(Attach a Certified copy of all Members ID Documents
and consortium agreement signed by all parties)

Section 21 Company





Government / Parastatals





Other (specify)




6 of 39

3. PREFERENCE POINTS CLAIMS


List all partners and shareholders (compulsory)
Name Position Citizenship
ID
Number
%
Ownership










Note: where owners are themselves a company or partnership, owners of the holding firm must
be identified.

HDI Ownership Status: Please read notes below very carefully

Instructions and Definitions:
(Please read carefully before completing HDI Ownership Status)

Owned: Having all the customary elements of ownership, including the right of decision-
making and sharing all the risks and profits commensurate with the degree of ownership
interests as demonstrated by an examination rather than the form of ownership arrangements.

Historically Disadvantaged Individuals (HDI ): For the purpose of registering as a supplier
for the Department, the refutable presumption shall be made that SA citizens who fall into
population groups that had no franchise in national elections prior to the introduction of the
1983 and 1993 constitution are Historically Disadvantaged Individuals. It is incumbent on
individuals to demonstrate their claims to fall into such population groups on the basis of
identification and association with and recognition by the members of such a group.

Women: A female person who is a SA citizen.

Establishment of HDI / Women Equity Ownership in a enterprise: Equity ownership shall
be equated to the percentage of an enterprise which is owned by individuals, or in the case of a
company, the percentage shares that are owned by individuals who are actively involved in the
management and daily business operations of the enterprise and exercise control over the
enterprise, commensurate with their degree of ownership.


Where individuals are not actively involved in the management and daily business operations
and do not exercise control over the enterprise commensurate with their degree of
ownership, equity ownership may not be claimed.




Siyabonga Mjwara Executive Director RSA 731001 5403 088 100
7 of 39
HDI Ownership Status:

Historically Disadvantaged Individuals (HDI) % %
Women Equity (WE) %
Disabled Individuals (DI) %

4. SMME status of your enterprise
- Please use this table to determine the SMME status of your enterprise
- Please the relevant box in each column

B. Full time paid employees C. Annual Turnover (millions) D. Total Gross asset value (million)
(property excluded)
A. Sector
Medium Small Very
Small
Micro Medium Small Very
Small
Micro Medium Small Very
Small
Micro
Agriculture 100 50 10 5 4 2 0.4 0.15 4 2 0.4 0.1
Mining &
Quarrying
200 50 20 5 30 7.5 3 0.15 18 4.5 1.8 0.1
Manufacturing 200 50 20 5 40 10 4 0.15 15 3.75 1.5 0.1
Construction 200 50 20 5 20 5 2 0.15 4 1 0.4 0.1
Retail & Motor 100 50 10 5 30 15 3 0.15 5 2.5 0.5 0.1
Wholesale
Trade
100 50 10 5 50 25 5 0.15 8 4 0.5 0.1
Catering,
Accommodation
100 50 10 5 10 5 1 0.15 2 1 0.2 0.1
Transport,
Storage
100 50 10 5 20 10 2 0.15 5 2.5 0.5 0.1
Finance &
Business
Services
100 50 10 5 20 10 2 0.15 4 2 0.4 0.1
Repairs/Allied
Services
100 50 10 5 30 15 3 0.15 5 2.5 0.5 0.1
Communication
s
100 50 10 5 20 10 2 0.15 5 2.5 0.5 0.1
Other Trade 100 50 10 5 10 5 1 0.15 2 1 0.2 0.1
Commercial
Agent
100 50 10 5 50 25 5 0.15 8 4 0.5 0.1
Community &
Social Services
100 50 10 5 10 5 1 0.15 5 2.5 0.5 0.1
Personal
Services
100 50 10 5 10 5 1 0.15 5 2.5 0.5 0.1

SMME status of your entity Please the relevant box
(According to SMME table) (compulsory)

Micro
Very small
Small
Medium
Large


I/We confirm that the information provided in paragraph 3 is correct as at this date



Name in print Signature Designation Date

100

Siyabonga Mjwara Executive Director

8 of 39
5. DECLARATION

Verification of information supplied in this document, including attached documents:

I/We, the undersigned, warrants that he / she is duly authorised to do so on behalf of the supplier,
certifies that the information supplied including the annexure, is correct and accurate and
acknowledge that:

If I found that the information supplied is incorrect the Department of Justice and Constitutional
Development will disqualify and remove the supplier from our database permanently.

TERMS AND CONDITIONS

- The Department of Justice and Constitutional Development can not guarantee business
opportunities. All procurement will be subject to the departmental SCM policy, the general
conditions of contract, and applicable legislation.
- All suppliers will be subjected to regular performance service review and could be
deregistered if service levels are not maintained.
- The validity period of a quotation must be at least 30 ( thirty) days
- Certified documents: Please ensure that The Commissioner of Oath has certified your
company registration documents, and other documents.
- Original Tax Clearance Certificate
- All shareholders/ Directors/ Members and in case of one-man concern, please furnish identity number
plus copy of identity documents
- Verification information supplied will perform against third party source such as SARS,
CIPRO, Safety net, etc.
- Please notify the Department immediately of any change to the provided information.
- Pleas ensure all fields are completed. Incomplete application forms will not be processed.

Should you have any queries or if you require assistance completing the form please
contact the Research and Development unit of Department of Justice on the following
numbers: 012 357 8198 / 012 315 1682.


Supplier Name: ____________________________________________________________


________________________________________ __________________________
Signature of Authorised Representative Signatory Name in Print

________________________________________ __________________________

Signatory Capacity: Signatory ID Number:


Signed at __________________________ on this ____ day of________________ 20___
Hlosi Holdings (Pty) LTD
Siyabonga Mjwara
Executive Director
731001 5403 088
Durban 05 April 12
9 of 39





6. SUPPLIER MAINTENANCE FORM:


BAS JYP PERSAL







PLEASE WRITE IN BLOCK LETTERS




I/We hereby request and authorise you to pay any amounts, which may accrue to me/us to the credit of my/our account
with the mentioned bank.


I/we understand that the credit transfers hereby authorised will be processed by computer through a system known as
"ACB - Electronic Fund Transfer Service", and I/we understand that not additional advice of payment will be provided by
my/our bank, but that the details of each payment will be printed on my/our bank statement or any accompanying
voucher. (This does not apply where it is not customary for banks to furnish bank statements).


I/we understand that the Department will supply a payment advice in the normal way, and that it will indicate the date on
which the funds will be made available on my/our account.


This authority may be cancelled by me/us by giving 30 days notice by prepaid registered post.

Please ensure that the information is validated as per required bank screens

I/We understand that bank details provided should be exactly as per the records held by the bank.

I/We understand that the Department will not assume responsibility for any delayed payments, as a result of incorrect
information supplied.

Company / Personal Details

Registered Name
Trading Name
Tax Number
VAT Number
Title:
Initials:
First Name:
Surname:



Regional Office Only
Region:
Reference Number:
Contact person:
Contact Telephone number:
Contact Fax number:
Head Office Only
Captured By:
Date Captured:
Authorised By:
Date Authorised:
Supplier code:
SUPPLIER NO

Hlosi Holdings (Pty) LTD
Hlosi Supplies & Logistics
9102377182
Mr.
SRM
Siyabonga
Mjwara
10 of 39
Address Detail

Postal Address
( Compulsory if Supplier )


Postal Code

New Detail

New Supplier information Update Supplier information

Supplier Type: Individual Department Partnership
Company Trust
CC Other ( Specify )

Department Number

Supplier Account Details
(Please note that this account MUST be in the name of the supplier. No 3rd party payments allowed).
Account Name


Account Number
Branch Name
Branch Number

Account Type
Cheque Account


Savings Account


Transmission Account


Bond Account


Other (Please Specify)


ID Number IF SPOUSE ACC HOLDER

Passport Number

Company Registration Number / /

*CC Registration
*Please include CC/CK where applicable
306 Waverley Court
54 Margaret Mncadi Avenue
Durban
4 0 0 1
H l o s i H o l d i n g s ( P t y ) L T D
6 2 3 2 5 6 5 7 0 5 7
Natal Branch
2 0 1 1 1 0 5 4 3 0 7
11 of 39

Practise Number

Bank stamp
PLEASE ATTACHED A PRINTOUT It is hereby confirmed that this details have been verified
FROM THE BANK against the following screens:
ABSA-CIF screen
FNB-Hogans system on the CIS4
PLEASE PROVIDE BANK STAMP STD Bank-Look-up-screen
PLUS SIGNITURE OF OFFICIAL Nedbank- Banking Platform under Client Details Tab

Contact Details

Business

Area
Code Extension
Home

Area
Code Extension
Fax

Area
Code
Cell
Cell Code

Email Address:

Contact Person:













Supplier Signature



Print Name







/ /
Date (dd/mm/yyyy)


NB: All relevant fields must be completed






0 8 6 2 3 5 5 9 8 6
0 7 2 9 2 3 0 5 3 4
mandla.mjwa@gmail.com
Mandla Mjwara
Siyabonga Mjwara
0 5 0 4 2 0 1 2
12 of 39
Section 7
LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS
AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY.

IMPORTANT CONDITION:

ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC
PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR
SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER
DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS
CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.1 Eastern Cape Province
Mark with X Mark with X
Aberdeen Port St Johns (Umzimvubu)
Adelaide Queenstown
Albany Qumbu
Albert Somerset East
Alexandria St Marks
Aliwal North Sterkstroom
Barkly East Steynsburg
Bathurst Steytlerville
Bedford Stutterheim
Bizana Tabankulu
Butterworth Tarka
Cathcart Tsolo
Cradock Tsomo
East London Uitenhage
Elliot Umtata
Elliotdale Umzimkulu
Engcobo Venterstad
Flagstaff Victoria East
Fort Beaufort Willowmore
Glen Grey Willowvale (Gatyana)
Graaff-Reinet Wodehouse
Hankey Xalanga (Cala)
Herschel Zwelitsha
Hewu Jansenville
Hofmeyr Joubertina
Humansdorp Keiskammahoek
Idutywa Kentani
Indwe

King Williams Town
13 of 39
Section 7

LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS
AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY.

IMPORTANT CONDITION:

ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC
PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR
SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER
DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS
CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION



7.1 Eastern Cape Province
Location Mark with X Location Mark with X
Kirkwood Mount Ayliff
Komga Mount Fletcher
Lady Grey Mount Frere
Libode Mpofu (Stockenstrm)
Lusikisiki Mqanduli
Maclear Ngqeleni
Matatiele Nqamakwe
Mdantsane Ntabathemba
Middelburg Pearston
Middledrift Peddie
Molteno Port Elizabeth

14 of 39
Section 7
LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS
AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY.

IMPORTANT CONDITION:

ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC
PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR
SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER
DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS
CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION
7.2 Free State Province
Location Mark with X Location Mark with X
Bethlehem Marquard
Bethulie Memel
Bloemfontein Odendaalsrus
Boshof Parys
Bothaville Paul Roux
Botshabelo Petrusburg
Brandfort Petrus Steyn
Bultfontein Philippolis
Clocolan Reddersburg
Dealesville Reitz
Dewetsdorp Rouxville
Edenburg Sasolburg
Edenville Senekal
Excelsior Smithfield
Fauresmith Springfontein
Ficksburg Steynsrus
Fouriesburg Thaba Nchu
Frankfort Theunissen
Harrismith Trompsburg
Heilbron Ventersburg
Hennenman Viljoenskroon
Hertzogville Villiers
Hobhouse Virginia
Hoopstad Vrede
Jacobsdal Vredefort
Jagersfontein Warden
Kestell Welkom
Koffiefontein Wepener
Koppies Wesselsbron
Kroonstad Winburg
Ladybrand Witsieshoek
Lindley Zastron


15 of 39
Section 7
LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS
AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY.

IMPORTANT CONDITION:

ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC
PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR
SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER
DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS
CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.3 Gauteng Province
Location Mark with X
Alberton
Benoni
Daveyton
Boksburg
Brakpan
Bronkhorstspruit
Cullinan
Germiston
Heidelberg
Johannesburg Regional Office
Kempton Park
Tembisa
Krugersdorp
Meyerton
Nigel
Oberholzer
Pretoria ( Include Supply to the National Office)
Atteridgeville
Pretoria North
Mamelodi
Randburg
Randfontein
Roodepoort
Soshanguve
Springs
Vanderbijlpark
Sebokeng
Vereeniging
Westonaria





16 of 39
Section 7

LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVID ERS MUST INDICATE BY M EANS OF AN X WHE RE GOODS
AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY.

IMPORTANT CONDITION:

ONLY E NTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC
PROVINCE AND LO CATED IN THE SPECIFIC PROVINCE WHERE T HE GOO DS AND/ OR
SERVICES WILL BE CO NSIDERED FOR RE GISTRATION ONTO DoJ & CD SUPPLIER
DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS
CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION


7.4 Kwazulu Natal Province (continued on page 17)
COURTS IN KZN Mark with X COURTS IN KZN Mark with X
Babanango Manguzi
Bergville Maphumulo
Camperdown Matatiele
Chatsworth Melmoth
Colenso Mooiriver
Dannhauser Mpumalanga
Dukuza Msinga
Dundee Mtubatuba
Durban Mtunzini
Emlazi Ndwedwe
Ekuvukeni New hanover
Empangeni Newcastle
Emzumbe Nkandla
Enseleni Nongoma
Eshowe Nqutu
Estcourt Ntuzuma
Emnabithi Ongoye
Glencoe Paulpietersburg
Greytown Phungashe
Harding Pietermaritzburg
Himeville Pinetown
Hlabisa Pongola
Hlanganani Port shepstone
Howick Richmond
Impendle Scottburgh
Ingwavuma Simdlagentsha
Inkanyezi Stanger
Ixopo State attorney
Izingolweni Ubombo
Kokstad

Umbumbulu


17 of 39
Section 7

7.4 Kwazulu Natal Province
COURTS IN KZN Mark with X COURTS IN KZN Mark with X
Kranskop Umzimkhulu
Kwamsane Utrecht
Ladysmith Verulam
Louwsburg Vryheid
Madadeni Vulamehlo
Magudu Weenen
Mahlabatini




LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS
AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY.

IMPORTANT CONDITION:

ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC
PROVINCE AND LOCATED IN THE SPECIFIC PROVINCEWHERE THE GOODS AND/OR
SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER
DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS
CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.5 Limpopo Province
Location Mark with X Location Mark with X
Bochum Phalala
Bolobedu Pietersburg
Dzanani Potgietersrus
Ellisras Praktiseer
Giyani Ritavi
Hlanganani Sekgosese
Letaba Sekhukhuneland
Lulekani Seshego
Malamulele Soutpansberg
Mankweng Thabamoopo
Mapulaneng Thabazimbi
Messina Thohoyandou
Mhala Tshilwavhusiku
Mokerong Tshitale
Mutale Vuwani
Namakgale Warmbaths
Naphuno Waterberg
Nebo Tshitale
Phalaborwa



18 of 39
Section 7


LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS
AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY.

IMPORTANT CONDITION:

ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHINTHE SPECIFIC
PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR
SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER
DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS
CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION


7.6 Mpumalanga Province
Location Mark with X Location Mark with X
Amsterdam Lydenburg
Amersfoort Mbibana
Balfour Mdutjana
Barberton Middelburg
Belfast Mkobola
Bethal Morgenzon
Breyten Moutse
Carolina Nelspruit
Delmas Nkomazi
Eerstehoek Nsikazi
Ekangala Piet Retief
Ermelo Sabie
Evander Standerton
Graskop Volksrust
Groblersdal Wakkerstroom
Hendrina Waterval Boven
Kriel White River
KwaMhlanga

Witbank













19 of 39
Section 7

LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED

PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS
AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY.

IMPORTANT CONDITION:

ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC
PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR
SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER
DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS
CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION


7.7 Northern Cape
Location Mark with X Location Mark with X
Barkly West Keimoes
Britstown Kenhardt
Calvinia Kimberley
Carnarvon Kuruman
Colesberg Noupoort
De Aar Olifantshoek
Douglas (Herbert) Philipstown
Fraserburg Pofadder
Galeshewe Port Nolloth
Garies Postmasburg
Griekwastad (Hay) Prieska
Groblershoop Richmond
Hanover Springbok (Namakwaland)
Hartswater Sutherland
Hopetown Upington (Gordonia)
Jan Kempdorp Victoria West
Kakamas Warrenton
Kathu

Williston















20 of 39
Section 7

LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED


PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS
AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY.

IMPORTANT CONDITION:

ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC
PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR
SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER
DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS
CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.8 North West Province
Location Mark with X
Bafokeng
Bloemhof
Brits
Christiana
Coligny
Delareyville
Ditsobotla
Ganyesa
Klerksdorp
Koster
Kudumane (Tlhaping-Tlharo)
Lehurutshe
Lichtenburg
Madikwe
Mankwe
Marico
Molopo
Moretele
Odi
Potchefstroom
Rustenburg
Schweizer-Reneke
Swartruggens
Taung
Ventersdorp
Vryburg
Wolmaransstad




21 of 39
Section 7

LOCATION WHERE GOODS AND/OR SERVICES MAY BE REQUIRED


PROSPECTIVE SERVICE PROVIDERS MUST INDICATE BY MEANS OF AN X WHERE GOODS
AND/OR SERVICE CAN BE PROVIDED BASED ON THE LOCATION OF THEIR ENTITY.

IMPORTANT CONDITION:

ONLY ENTITIES REGISTERED WITH THE RELEVANT AUTHORITIES WITHIN THE SPECIFIC
PROVINCE AND LOCATED IN THE SPECIFIC PROVINCE WHERE THE GOODS AND/OR
SERVICES WILL BE CONSIDERED FOR REGISTRATION ONTO DoJ & CD SUPPLIER
DATABASE ( Read the conditions set out in this application) . FAILING TO COMPLY WITH THIS
CONDITION WILL INVALIDATE THE PRSOPECTIVE SUPPLIERS APPLICATION

7.9 Western Cape Province
Location Mark with
X
Location Mark with
X
Albertinia Montagu
Atlantis Moorreesburg
Beaufort West Mossel Bay
Bellville Murraysburg
Bonnievale Oudtshoorn
Bredasdorp Paarl
Caledon Piketberg
Calitzdorp Porterville
Cape Town Prince Albert
Ceres Riversdale
Clanwilliam Robertson
George Simons Town
Goodwood Somerset West
Grabouw Stellenbosch
Heidelberg Strand
Hermanus Swellendam
High Court Cape Town Tulbagh
Hopefield Uniondale
Khayelitsha Van Rhynsdorp
Knysna Vredenburg
Kuils River Vredendal
Laaiplek Wellington
Ladismith Wolseley
Laingsburg Worcester
Malmesbury Wynberg
Mitchells Plain Riversdale





22 of 39

8. LIST OF COMMODITY SPECIFICS

IMPORTANT NOTICE: PROSPECTIVE SERVICE PROVIDERS MUST MARK ONLY FIVE (5) COMMODITIES
SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS. FAILURE TO COMPLY WITH THIS CONDITION WILL
INVALIDATE THE PROSPECTIVE SERVICE PROVIDERS APPLICATION
No Des cription
Mark
with
an X
No Description
Mark
with an
X
1 Access Control Systems 29 Computer Consumables
2 Artwork and Painting 30 Computer Hardware, Printer &
Components

3 Advertising (in electronic and print
media)
31 Computer Networking Contractors
4 Air Conditioning System - Supply and
Repairs
32 Computer: Video & Audio
Conferencing

5 Anti Virus Software 33 Conferencing Systems
6 Asset Management System Bar-
codes
34 Conference Venues
7 Auctioneers 35 Consulting: Asset Management
8 Audio Visual 36 Consulting: Advertising
9 Awnings 37 Consulting: Auditors
10 Banking Services 38 Consulting: Business Advisor
Services

11 Bags, Refuse and Plastic 39 Consulting: Business process
analysis and re engineering

12 Binding Services 40 Consulting: Business Strategy
13 Badges Conference, embroidered,
metal
41 Consulting: Contract Law
14 Batteries 42 Consulting: Communication
Management

15 Books & Journals 43 Consulting: Communications
16 Blinds 44 Consulting: Competency
Assessment

17 Cashiering Services 45 Consulting: Computer Consulting
Services

18 Catering services 46 Consulting: Customer Interface
19 Cellular phone providers 47 Consulting: Customer Satisfaction
20 Change Management 48 Consulting: Emergency &
Disaster Management

21 Cleaning Chemicals 49 Consulting: Empowerment
Women

22 Cleaning Services 50 Consulting: Employee Health &
Wellness

23 Carpets 51 Consulting: Employment Equity
and Transformation

24 Clothing General/Protective &
Uniforms
52 Consulting: Entrepreneurial Skills
25 Curtaining, Rails and Accessories 53 Consulting: Environmental
26 Clothing General/Protective &
Uniforms
54 Consulting: Executive Coaching
27 Computer Repairs & Maintenance 55 Consulting: Erection Engineers
28 Coffee and vending machines 56 Consulting: Evaluation Assets



23 of 39
8. LIST OF COMMODITY SPECIFICS

IMPORTANT NOTICE: PROSPECTIVE SERVICE PROVIDERS MUST MARK ONLY FIVE (5) COMMODITIES
SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS. FAILURE TO COMPLY WITH THIS CONDITION WILL
INVALIDATE THE PROSPECTIVE SERVICE PROVIDERS APPLICATION
No Des cription
Mark
with
an X
No Des cription
Mark with
an X
57 Consulting: Exhibitions 88 Consulting: Litigation
58 Consulting: Exports & Imports 89 Consulting: Library Services
59 Consulting: Financial and accounting
services
90 Consulting: Logistical Services
60 Consulting: Financial and System
Integration
91 Consulting: Logistical System
61 Consulting: Financial Administration 92 Consulting Management
62 Consulting: Financial Planning 93 Consulting: Management Tools
63 Consulting: Financial Systems 94 Consulting: Marketing and
Advertising

64 Consulting: Fleet Service
Management
95 Consulting: Media Relation
65 Consulting: Forensic Investigation 96 Consulting: Motivational
speakers

66 Consulting: Fund Management 97 Consulting: Organizational
Design

67 Consulting: Furnaces 98 Consulting: People
Transformation

68 Consulting: Geographical Information 99 Consulting: Performance
management

69 Consulting: Governance 100 Consulting: Policy Development
70 Consulting: Health Care 101 Consulting: Psychological
Counselling

71 Consulting Human Resources 102 Consulting: Project
Management

72 Consulting: Impact Assessment 103 Consulting: Public Relations
Management

73 Consulting: Industrial 104 Consulting: Psychological
Assessment

74 Consulting: Information technology &
Strategy
105 Consulting: Recruitment
Services

75 Consulting: Institutional 106 Consulting: Remuneration
76 Consulting: Infrastructure 107 Consulting: Research and
Development

77 Consulting: Insurance 108 Consulting: Risk Management
78 Consulting: Interior Decorating 109 Consulting: Skills Development
79 Consulting: Investigation Services 110 Consulting: Survey Research
80 Consulting: Knowledge management 111 Consulting: Talent Management
81 Consulting: Job Evaluation 112 Consulting: Team Building
82 Consulting: Journalism 113 Consulting: Training &
Development

83 Consulting: Laboratory 114 Consulting: Tracing Agency &
Debt Collection

84 Consulting: Labour Relations 115 Consulting: Website Design
85 Consulting: Landscape Services 116 Corporate Uniform
86 Consulting: Legal Services 117 Courier & Mailing Services
87 Consulting: Legislation Drafting 118 Crockery & Cutlery
24 of 39




8. LIST OF COMMODITY SPECIFICS
MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS
No Des cription
Mark
with
an X
No Des cription
Mark
with
an X
119 Drain cleaning services 156 Gift Promotional
120 Drivers licences permits & Lessons 157 Gardening Services
121 Editing Services 158 Gas and Heating Equipment
122 Electrical Appliances 159 Glassing Contractors
123 Electrical Appliances Household 160 Government Services
124 Electrical Component and Equipment 161 Graphic Design Services
125 Electrical Contractors & Maintenance 162 Government Services
126 Electrical Conveyors 163 Globes, lamps & Fluorescent
tubes

127 Embossing Services 164 Guesthouse & lodges
128 Emergency Medical Suppliers and
Equipment
165 Hardware and Building
Supplies

129 Elevators, Conveyors and
Maintenance & repairs
166 Heaters and Heating
Equipment

130 Encoding 167 Hiring of Equipment (Sound
System & Audio visual)

131 Encrypting software and system 168 Hospitality Service Corporate
132 Engraving Services 169 ID card personalisation
system

133 Engraving Services and Equipment 170 Illustration services
134 Entertainment ( Performers) 171 Imaging Services
135 Entertainment Facilities 172 Illustration services
136 Entertainment Services( Tourists) 173 Industrial chemicals
137 Entertainment Venues and Theatres 174 Information services
138 Envelopes 175 Inspection services
139 Estate Agencies and Consultants 176 Institutes
140 Evacuation Systems 177 Insulation Services
141 Event and Conferencing
Management
178 Intercommunication System
142 Exhibition Centres/Stands 179 Interior Designers
143 Facilitation General Services 180 Interpretation services
magnetic surveys

144 Facilitation Services Conferences 181 Interpreting services
languages

145 Fencing Contractors 182 Irrigation contractors
146 Fire Extinguishing 183 Hotel Accommodation
147 Flags and Maps 184 Labels and Labelling services
148 Flooring Contractors 185 Lightning Contractors
149 Florist 186 Locksmiths
150 Footwear 187 Logo: Crockery
151 Framing Services 188 Logo: Design services
152 Franking Machines 189 Logo Engraving
153 Freight Services ( Air, Land and Sea) 190 Licences (Radio & T.V)
154 Furniture removals( Office Furniture) 191 Marketing and
communications Services

155 Gardening Services

192 Market Research
25 of 39
8. LIST OF COMMODITY SPECIFICS
MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS

No Des cription
Mark
with
an X
No Des cription
Mark
with
an X
193 Media Liaison 229 Renovation Services
194 Media/publicity 230 Recording and Transcription
Services

195 Mediator Services 231 Roofing Contractors
196 Mobile homes 232 Safes and Safe removal
Services

197 Network Solutions 233 Sanitary ware
198 Newspapers and Magazines 234 Secretarial Services
199 Number plates 235 Self Defence Training
200 Office Automation Hire 236 Security Equipment - Supply
and Repairs

201 Office furniture 237 Security and Safety services
202 Office Layout Design Services 238 Security Transit
203 Office Buildings Maintenance &
Repairs
239 Seminars
204 Office Machines and Equipment 240 Service Providers Cellular
Telephones

205 Organizational Development 241 Signs
206 Packing Material 242 Stationery
207 Paint Supplies 243 Storage facility
208 Partitioning Contractors 244 Storage Systems
209 Paintings 245 Shelves & Shelving
210 Pest Control Services 246 Supply of printed publications
211 Photography Equipment 247 Translation Services
212 Photography Services 248 Transportation service (
including chauffeur services)

213 Plants, Flowers & Decoration 249 Travel agency
214 Printing 250 Telecommunication
Equipment

215 Printing of booklets and
publications(design, layout and
printing)
251 Telecommunication System
216 Promotional material 252 Tiling Contractors
217 Property Management Services 253 Time and Attendance
Equipment

218 Photography Services 254 Tools and Electrical
Mechanical

219 Plumbing Contractors

255 Toilet Paper
220 Professional Bodies & Membership
fees
256 Tours and Tourism
221 Publishers 257 Tracking Service Security
222 Quality control services 258 Tracking Service Vehicle
223 Radio Equipment 259 Training Material and
Software

224 Recreation Centers 260 Training Assets Software
225 Recycling Services 261 Training Business Software
226 Refrigeration Equipment and
Repairs
262 Training Business Skills
227 Refuse Conveyers 263 Training Communication
228 Rehabilitation Services Alcohol and
Drug Depend


264 Training: Communication
Strategies and Systems

26 of 39
LIST OF COMMODITY SPECIFICS
MARK ONLY FIVE (5) COMMODITIES SPECIFIC AS PER THEIR PRINCIPAL/CORE BUSINESS
No Des cription
Mark
with
an X
No Des cription
Mark
with
an X
265 Training: Community Building 306 Vehicle Audio and Equipment
266 Training: Community Services 307 Vehicle Hiring
267 Training Computer Literacy 308 Vehicle Industry
268 Training: Computer Programming
and Software
309 Vehicle Security and Tracking
System

269 Training: Computer System and
Solution
310 Verification Services
270 Training: Conference and Venues 311 Video Recording Services
271 Training: Customer Interactions 312 Venue finders
272 Training: E- Business Strategies 313 Warehouse Services
273 Training: Economic Strategy 314 Waste Disposal
274 Training; Education 315 Waterproofing Contractors
275 Training: Employee Development 316 Window Fitting and Glasses
276 Training: Empowerment Models 317 Web pages and Design
277 Training: Entrepreneurial Skills 318 Web solution Design and
Maintenance

278 Training: Financial Administration 319 Welding Consultants
279 Training: Financial Planning 320 Window Fitting and Glass
280 Training: Financial Systems 321 Wire works General
281 Training: Human Resources 322 Workshop Equipment
282 Training: Information Management 323 Workshop Facilitation
283 Training: IT Services and Strategies 324 Workshop Requisites
284 Training: Labour 325 Writing Articles and Editorials
285 Training: Logistics Systems 326 Writing Services
286 Training: Management
287 Training: Management Tools
288 Training: Multimedia
289 Training: Perfomance Management
290 Training: Personnel Development
291 Training: Project Management
292 Training: Public Relations and
Services

293 Training: Risk Management
294 Training: Secretarial
295 Training: Security Systems
296 Training: Skills Development
297 Training Software Business
298 Training: Stress Management
299 Training: Technical Skills
300 Training: Stress Management
301 Training: Technical Skills
302 Training: Township and Rural
Projects

303 Transcription Services
304 Travel Agency
305 Tyres and Tubes






27 of 39
PREFERENCE POINTS CLAIM FORM IN TERMS OF THE
PREFERENTIAL PROCUREMENT REGULATIONS 2001

PURCHASES
Section 9


This preference form must form part of all bids invited. It contains general information and
serves as a claim form for Historically Disadvantaged Individual (HDI) preference points as
well as a summary for preference points claimed for attainment of other specified goals

NB: BEFORE COMPLETING THIS FORM , BIDDE RS MUST STUDY T HE GENER AL
CONDITIONS, DEFINITIONS AND DIRECTIVES APPLICABLE IN RESPECT OF EQUITY
OWNERSHIP BY HIS TORICALLY DISA DVANTAGED IN DIVIDUALS ( HDIs), AS
PRESCRIBED IN THE PREFERENTIAL PROCUREMENT REGULATIONS, 2001.


1. GEN ERAL CONDITIONS

1.1 The following preference point systems are applicable to all bids:

- the 80/20 system for requirements with a Rand value of up to R500 000; and


1.2 The value for these quotations is estimated to exceed/not exceed R500 000 and therefore
the 80/20 system shall be applicable.

1.3 Preference points for this bid shall be awarded for:

(a) Price; and
(b) Specific contract participation goals, as specified in the attached forms.

1.3.1 The points for this bid are allocated as follows:
POINTS
1.3.1.1 PRICE 80


1.3.1.2 SPECIFIC CONTRACT PARTICIPATION GOALS

(a) Histori cally Disadvantaged Individuals:

(i) who had no franchise in national elections before
the 1983 and 1993 Constitutions 10
(ii) who is a female 7
(iii) who has a disability 3

(b) Other specific goals (goals of the RDP- plus local manufacture)
(i) .
(ii) .
(iii) .
(iv) .

Total points for Price, HDIs and other RDP-
goals must not exceed 100

Separate Preference Points Claim Forms will be used for the promotion of the
specific goals for which points have been allocated in paragraph 1.3.1.2 (b) above.
28 of 39


1.4 Failure on the part of a bidder to fill in and/or to sign this form may be interpreted to mean
that preference points are not claimed.

1.5. The purchaser reserves the right to require of a bidder, either before a bid is adjudicated or
at any time subsequently, to substantiate any claim in regard to preferences, in any manner
required by the purchaser.

2. GENERAL DEFINITIONS

2.1 Acceptable quotations means any quotation which, in all respects, complies with the
specifications and conditions of bid as set out in the bid document.

2.2 Quotation means a written offer in a prescribed or stipulated form in response to an
invitation by an organ of state for the provision of goods, works or services.

2.3 Comparative price means the price after the factors of a non-firm price and all
unconditional discounts that can be utilised have been taken into consideration.

2.4 Consortium or joint venture means an association of persons for the purpose of
combining their expertise, property, capital, efforts, skills and knowledge in an activity for
the execution of a contract.

2.5 Contract means the agreement that results from the acceptance of a bid by an organ of
State.

2.6 Specific contract participation goals means the goals as stipulated in the Preferential
Procurement Regulations 2001.

2.6.1 In addition to above-mentioned goals, the Regulations [12.(1)] also make provision for
organs of state to give particular consideration to procuring locally manufactured products.

2.7 Control means the possession and exercise of legal authority and power to manage the
assets, goodwill and daily operations of a business and the active and continuous exercise
of appropriate managerial authority and power in determining the policies and directing the
operations of the business.

2.8 Disability means, in respect of a person, a permanent impairment of a physical,
intellectual, or sensory function, which results in restricted, or lack of, ability to perform an
activity in the manner, or within the range, considered normal for a human being.

2.9 Equity Ownership means the percentage ownership and control, exercised by individuals
within an enterprise.

2.10 Historically Disadvantaged Individual (HDI) means a South African citizen

(1) who, due to the apartheid policy that had been in place, had no franchise in national
elections prior to the introduction of the Constitution of the Republic of South Africa,
1983 (Act No 110 of 1983) or the Constitution of the Republic of South Africa, 1993,
(Act No 200 of 1993) (the interim Constitution); and/or

(2) who is a female; and/or

(3) who has a disability:

provided that a person who obtained South African citizenship on or after the coming
to effect of the Interim Constitution, is deemed not to be a HDI;

29 of 39
2.11 Management means an activity inclusive of control and performed on a daily basis, by
any person who is a principal executive officer of the company, by whatever name that
person may be designated, and whether or not that person is a director.

2.12 Owned means having all the customary elements of ownership, including the right of
decision-making and sharing all the risks and profits commensurate with the degree of
ownership interests as demonstrated by an examination of the substance, rather than the
form of ownership arrangements.

2.13 Person includes reference to a juristic person.

2.14 Rand value means the total estimated value of a contract in Rand denomination that is
calculated at the time of bid invitations and includes all applicable taxes and excise duties.

2.15 Small, Medium and Micro Enterprises (SMMEs) bears the same meaning assigned to
this expression in the National Small Business Act, 1996 (No 102 of 1996).

2.16 Sub-contracting means the primary contractors assigning or leasing or making out work
to, or employing another person to support such primary contractor in the execution of part
of a project in terms of the contract.

2.17 Trust means the arrangement through which the property of one person is made over or
bequeathed to a trustee to administer such property for the benefit of another person.

2.18 Trustee means any person, including the founder of a trust, to whom property is
bequeathed in order for such property to be administered for the benefit of another person.

3. ESTABLISHMENT OF HDI EQUITY OWNERSHIP IN AN ENTERPRISE

3.1 Equity ownership shall be equated to the percentage of an enterprise which is owned by
individuals classified as HDIs, or in the case of a company, the percentage shares that are
owned by individuals classified as HDIs, who are actively involved in the management and
daily business operations of the enterprise and exercise control over the enterprise,
commensurate with their degree of ownership.

3.2 Where individuals are not actively involved in the management and daily business
operations and do not exercise control over the enterprise commensurate with their degree
of ownership, equity ownership may not be claimed.

4. ADJUDICATION USING A POINT SYSTEM

4.1 The bidder obtaining the highest number of points will be awarded the contract.

4.2 Preference points shall be calculated after prices have been brought to a comparative
basis.

4.3 Points scored will be rounded off to 2 decimal places.

4.4 In the event of equal points scored, the bid will be awarded to the bidder scoring the highest
number of points for specified goals.
30 of 39

5. POINTS AWARDED FOR PRICE

5.1 THE 80/20 PREFERENCE POINT SYSTEMS

A maximum of 80 or 90 points is allocated for price on the following basis:




80/20



|
.
|

\
|
=
min
min
1 80
P
P Pt
Ps
Where

Ps = Points scored for price of bid under consideration

Pt = Rand value of bid under consideration

Pmin = Rand value of lowest acceptable bid

6. Points awarded for historically disadvantaged individuals

6.1 In terms of Regulation 13 (2) preference points for HDIs are calculated on their percentage
shareholding in a business, provided that they are actively involved in and exercise control
over the enterprise. The following formula is prescribed in Regulation 13 (5) (c):


100
EP
NOP NEP =

Where

NEP = Points awarded for equity ownership by an HDI

NOP = The maximum number of points awarded for equity ownership by an HDI in that
specific category

EP = The percentage of equity ownership by an HDI within the enterprise or business,
determined in accordance with the definition of HDIs.

6.2 Equity claims for a trust will only be allowed in respect of those persons who are both trustees
and beneficiaries and who are actively involved in the management of the trust.

6.3 Documentation to substantiate the validity of the credentials of the trustees contemplated
above must be submitted.

6.4 Listed companies and tertiary institutions do not qualify for HDI preference points.

6.5 A consortium or joint venture may, based on the percentage of the contract value managed or
executed by their HDI-members, be entitled to preference points in respect of an HDI.

6.6 A person awarded a contract as a result of preference for contracting with, or providing equity
ownership to an HDI, may not subcontract more than 25% of the value of the contract to a
person who is not an HDI or does not qualify for the same number or more preference for
equity ownership.

31 of 39
7. BID DECLARATION

7.1 Bidders who claim points in respect of equity ownership must complete the Bid Declaration at
the end of this form.

8. EQUITY OWNERSHIP CLAIMED IN TERMS OF PARAGRAPH 2.10 ABOVE. POINTS TO
BE CALCULATED FROM INFORMATION FURNISHED IN PARAGRAPH 9.8.

Ownership Percentage owned Po ints claimed
8.1 Equity ownership by persons who
had no franchise in the national elections %

8.2 Equity ownership by women % .

8.3 Equity ownership by disabled persons* %

*If points are claimed for disabled persons, indicate nature of impairment (see paragraph 2.8
above)



9 DECLARATION WITH REGARD TO EQUITY

9.1 Name of firm :.............................................................................................

9.2 VAT registration number :.............................................................................................

9.3 Company registration number :

9.4 TYPE OF FIRM

Partnership
One person business/sole trader
Close corporation
Company
(Pty) Limited
[TICK APPLICABLE BOX]

9.5 DESCRIBE PRINCIPAL BUSINESS ACTIVITIES

.. ..................................................................................................................................................
.............................................................................................................................................
.................


9.6 COMP ANY CLASSIFICATION

Manufacturer
Supplier
Professional service provider
Other service providers, e.g. transporter, etc.
[TICK APPLICABLE BOX]

100
Hlosi Holdings (Pty) LTD
2011/105437/07

32 of 39
9.7 TOTAL NUMBER OF YEARS THE FIRM HAS BEEN IN BUSINESS? ....

9.8 List all Shareholders by Name, Position, Identity Number, Citizenship, HDI status and
ownership, as relevant. Information to be used to calculate the points claimed in
paragraph 8.

* HDI Status
Name
Date/Position
occupied in
Enterprise
ID Number
Date RSA
Citizenship
obtained
No
franchise
prior to
elections


Women

Disabled

%
of
business /
enterprise
owned








*Indicate YES or NO


9.9 Consortium / Joint Venture

9.9.1 In the event that preference points are claimed for HDI members by consortia / joint
ventures, the following information must be furnished in order to be entitled to the
points claimed in respect of the HDI member:


Name of HDI member (to be
consistent with paragraph 9.8)
Percentage (%) of the contract value
managed or executed by the HDI member












2
Siyabonga
Mjwara 2011/11/01 7310015403088 yes no no 100
33 of 39
9.10 I/we, the undersigned, who warrants that he/she is duly authorised to do so on
behalf of the firm certify that points claimed, based on the equity ownership,
indicated in paragraph 8 of the foregoing certificate, qualifies the firm for the
preference(s) shown and I / we acknowledge that:

(i) The information furnished is true and correct.

(ii) The Equity ownership claimed is in accordance with the General
Conditions as indicated in paragraph 1 of this form.

(iii) In the event of a contract being awarded as a result of points claimed as
shown in paragraph 8, the contractor may be required to furnish
documentary proof to the satisfaction of the purchaser that the claims are
correct.

(iv) If the claims are found to be incorrect, the purchaser may, in addition to
any other remedy it may have -

(a) recover costs, losses or damages it has incurred or suffered as a
result of that persons conduct;

(b) cancel the contract and claim any damages which it has suffered
as a result of having to make less favourable arrangements due to
such cancellation;

(c) impose a financial penalty more severe than the theoretical
financial preference associated with the claim which was made in
the bid; and


WITNESSES: SIGNATURE(S) PROSPECTIVE SUPPLIER


1. ..



2.



DATE:..

ADDRESS: .....
.....
.....
.....









05/04/2012
306 Waverley Court
54 Margaret Mncadi Avenue
Durban
4001
34 of 39
Section 10
Declaration of Interest

1. Any legal person, including persons employed by the State, or persons who act on behalf
of the State or persons having a kinship with persons employed by the State, including a
blood relationship, may make an offer or offers in terms of the sourcing of quotations. In
view of possible allegations of favouritism, should the resulting quotation, or part thereof, be
awarded to persons employed by the State, or to persons who act on behalf of the State, or
to persons connected with or related to them, it is required that the service provider or his
authorized representative shall declare his or her positions vis--vis the evaluating authority
and/or take an oath declaring his or her interest, where -
- The service provider is employed by the State or acts on behalf of the State; and/or
- the legal person on whose behalf the supplier database application form or quotation
is signed, has a relationship with persons/a person who are/is involved with the
evaluation of the quotation(s), or where it is known that such a relationship exists
between the person or persons for or on who's behalf the declarant acts and persons
who are involved with the evaluation of the quotation.
2. In order to give effect to the above, the following questionnaire shall be completed and
submitted with the application to register on the CIPRO supplier database.
2.1 Are you or any person connected with the service provider, employed by the State? (Delete
that is not applicable)
*YES / NO
2.1.1 If so, state particulars.
Name & Surname: .
Physical & Postal Address: ..
Tel & number: ... Fax number: ...
Cell number/s: email address: .....
2.2 Do you, or any person connected with the service provider, have any relationship (family,
friend, other) with a person employed in the department concerned and who may be involved
with the evaluation or adjudication of this application or quotations? *YES / NO

2.2.1 if so, state particulars.
Name & Surname: .
Physical & Postal Address: ..
Tel & number: ... Fax number:....
Cell number/s: email address:..
n/a
n/a
35 of 39
2. 3 Are you, or any person connected with the service provider, aware of any relationship
(family, friend, other) between the service provider and any person employed by the department
concerned who may be involved with the evaluation or adjudication of this applicant or quotations?
*YES / NO
2.3.1 If so, state particulars.
Name & Surname: .
Physical & Postal Address:..
Tel & number: ... Fax number:
Cell number/s: email address: ..

2.4 Are any member or shareholder of the entity has been blacklisted with any Government
Department in the last five years and if so provide the details as an accompanying annexure
to this application. *YES / NO
Failing to provide full disclosure in respect to 2.4 will result in the invalidation of the
prospective service providers application.

2.4 All members and shareholders of the entity applying for registration must declare all other
business interest in any other entities, as an accompanying annexure to this application.
Failing to provide full disclosure in respect to 2.5 will result in the invalidation of the
prospective service providers application.

DECLARATION


I, THE UNDERSIGNED (NAME)

CERTIFY THAT THE INFORMATION FURNISHED THE SUPPLIER DATA BASE APPLICATION FORM
PARAGRAPHS 2.1 TO 2.3.1 OF THE DECLARATION OF INTEREST IS CORRECT. I ACCEPT THAT THE
DEPARTMENT MAY ACT AGAINST ME IN TERMS OF PARAGRAPH 34 OF THE GENERAL CONDITIONS
OF BID, CONTRACT AND ORDER SHOULD THIS DECLARATION PROVE TO BE FALSE.


_______
Signature Date




___________ __________ ____________
Position Name of Service Provider

n/a
Siyabonga Mjwara
05/04/2012
Executive Director
Hlosi Holdings (Pty) LTD
36 of 39
Section 11
DoJ & CD ANTI-CORRUPTION TOLL-FREE HOTLINE

0800 701 701

The aim of the Hotline is to enhance an honest work ethic and simultaneously provide
employees and persons not employed by the Department with a mechanism to bring any
unethical business practices to the attention of management.

DECLARATION

I, THE UNDERSIGNED (NAME)

CERTIFY THAT I AM AWARE OF DoJ & CD ANTI-CORRUPTION TOLL-FREE LINE,
WHERE I CAN FREELY REPORT POSSIBLE CORRUPT ACTIONS BY
SUPPLIERS/SERVICE PROVIDERS/CONTRACTORS OR POSSIBLE CORRUPT
ACTIONS WITHIN THE DEPARTMENT AT ANY TIME AND THAT THE DEPARTMENT
WILL TREAT MY IDENTITY AS STRICTLY CONFIDENTIAL.





Signature Date



Position Name of Service Provider













05/04/2012
Executive Director Hlosi Holdings (Pty)LTD
37 of 39
Section 13

13. SPECIAL CONDITIONS:

1. As per section 7 of this supplier registration form entitled Location where goods
and/or services may be required, prospective service providers must indicate by
means of an X where goods and/or service can be provided based on the location of
their entity. Only entities registered with the relevant authorities within the specific
province and located in the specific province where the goods or services will be
considered for registration onto DoJ & CD supplier database. Prospective suppliers
must submit a latest original Utility bill (water and electricity) and a certified copy of its
entity business registration in respect to the Province applied for. Failing to comply
with this condition will invalidate the prospective suppliers application.

2. A response to each element set out in section 14, Evaluation matrix (as per page 40)
per element must be prepared and submitted with the application to be considered
for registered as a supplier on DoJ & CD supplier database.

(a) Demonstrable experience in similar services undertaken as per principle
business (submit a list of four reference with contactable details, description
of goods and/or services rendered, at least four (4) letters of
recommendation where goods and/or services were rendered, value of
contract awarded)

(b) The prospective service providers or in the case of a joint venture, each
party to the joint venture must submit:
(i) original or certified copies of their entities bank statement for a
consecutive period of any three (3) months for the year 2009 and
2010; and
(ii) Certified copies of the latest Audited Annual Financial Statements,
or
(iii) In the case of a newly established entity, submit the latest Audited
Annual Financial Statement or recent financial results and the bank
statement for a consecutive period of any three (3) months for the
latest financial period Failure to compl y with b (i) and (ii) or (iii )
will automatically invalidates the prospective service providers
application.

3. Service providers scoring a total point of 60% or more for functionality will be
placed on DoJ & CD supplier database. Service providers who score less than
60% in respect of functionality will be regarded as having submitted a non
responsive application. Therefore service providers are requested to furnish
detailed information in substantiation of compliance to the requirements of the
evaluation criteria (Section 14).
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4. Government Procurement General Conditions of contract (GCC) as issued by
National Treasury will applicable on all instances. The general conditions is
available on the National Treasury website (www.treasury.gov.za)

5. No advance payment would be made for the procurement of goods or services.
Payment would be made in terms of the deliverables or other unless otherwise
agreed upon by other parties (DoJ & CD and the contractor). DoJ & CD will pay
within the prescribed period according to PFMA.

6. Service providers must complete and submit all relevant information/documentation
required below as insufficient information and non compliance to the conditions set
out will invalidate your application
Fax number
E-mail address
Physical address
Postal address
Tel number (s) as contact number
Cell number (s) as contact number
Location where goods and/or services may be required
Commodity listed ( only five (5) commodity specific as per principle
Business. Non compliance to this condition will i nvalidate the
prospective suppliers application)
Fill all forms completely
Sign all forms
Preference Points Claim Forms
Valid and original SARS Tax Cle arance Certificate (Failing to submit
an original valid Tax clearance certificate will invalidate the
prospective suppliers application)
Supplier Maintenance Form
Company / CC Registration Certificate (Issued by CIPRO).
A Business profile of entity of not more than five (5) pages.
All shareholders/ Directors/ Members and in case of one-man concern,
please furnish identity number plus copy of identity documents

3 A list of commodities requirements (page 23 to 27) are enlisted in the supplier
database application form. Prospective suppliers/service providers may apply to be
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enlisted on the supplier database for a maximum of five (5) commodities specific
as per their principle business. Where a prospective supplier has indicated more
than five commodities specific such application would not be considered for
evaluation further.

4 Successful supplier providers enlisted of the DoJ CD supplier database must
submit a new valid current Tax Clearance Certificate to the National Office
(Pretoria) before the validity of the current Certificate expires, in order to ensure
that the Department may continuously consider quotations submitted by your
business.

5 It is imperative that only the DoJ & CD supplier database registration form with
supporting documentation and Original Signatures be submitted. Applications with
copied signatures or any part of the supplier application that has been retyped or
redrafted will not be considered and disqualified for reegistration.

6 Suppliers providing information incorrectly or fraudulently in their Supplier
Database Registration form will be restricted from bidding, in addition to any other
action the Department of Justice and Constitutional Development may institute
against such a supplier. Furthermore, in the event of the DoJ & CD being
prejudiced financially, it reserves the right to take legal action against the supplier

Section 14

14. EVALUATI ON CRITERIA
Functionality will be evaluated on a scale of 0 4 in accordance with the criteria
below. The rating will be as follows: 0 = Non Response, 1= Poor, 2 = Average,
3 = Good, 4= Excellent

NO CRITERION: 0 1 2 3 4 WEIGHT SCORE
1 Demonstrable experience in
similar services undertaken
( submit a list of four
reference with contactable
details)



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2 Financial stability 30