Supplier Register

PA-23: Application for registration on the Supplier Register
Any reference to words Bid or Bidder herein and/or in any other documentation shall be construed to have the same meaning as the words Tender or
Tenderer. Page 1 of 12
or !nternal "se #ffective date $ecember 2%11 &ersion' 1.(
Page 1 of 12
Name of Firm: __________________________________________________
Applicant Name: ________________________________________________
Contact Person: ________________________________________________
Contact Person Tel. No: _________________________________________
For office use only
Received on: DD ______ MM ______ YY ______
Received y !print full name"
_____________________________________________________________
#i$nature: _________________ %ournal Numer: _________________
#upplier Re$istration Code: ________________
PA&'(: APP)*CAT*+N F+R R,-*#TRAT*+N A# A
#.PP)*,R +F -,N,RA) -++D# AND #,R/*C,#
+NT+ T0, DP1 #.PP)*,R# R,-*#T,R
Terms of Reference for Re$istration onto Department of Pulic 1or2s !DP1"
#uppliers Re$ister
3" T,RM# +F R,F,R,NC,
3.3" Department of Pulic 1or2s !DP1" #uppliers Re$istration Policy
The DPW has implemented a Supplier Register to ensure that the ha!e sufficient appropriatel "ualified suppliers
to pro!ide the Department #ith goods and ser!ices as and #hen re"uired$
3.'" #upplier!s" Re$istration onto t4e #uppliers Re$ister
Suppliers that #ish to register onto the Suppliers Register should complete the follo#ing:
The Application %orm &PA-23 Application for Registration as a Supplier of 'eneral 'oods and Ser!ices
onto the Suppliers Register(
Anne)ure 1 - &*ist of To#ns( 5 #uppliers 6ill only e re$istered for a specific to6n if t4ey 4ave an
office in t4at to6n.
Anne)ure 2 - &+ommodit +ategories(
Anne)ure 3 - &Suppliers ,aintenance and -an.ing details(
Returna/le Documents &Refer to 10$1 of PA-23(
#uppliers must complete a separate application form for eac4 ranc4 if t4e Firm 4as more t4an one
ranc4 office.
1.2.1) What does it mean to be registered on the Supplier Register?
Suppliers that ha!e /een registered onto the Suppliers Register ma ha!e the opportunit to /id or "uote on
the Department2s ac"uisition re"uirements$ Registration onto the Suppliers Register does not $uarantee
/usiness opportunities as all ac"uisition #ill /e su/3ect to the Suppl +hain ,anagement &S+,( polic of
DPW$
3.(" Maintenance of t4e #uppliers Re$ister
The Department of Pu/lic Wor.s &4ead 5ffice( #ill update suppliers2 information on an ongoing /asis$
Suppliers that ha!e registered onto the Suppliers Register should ensure that the furnish the Department
#ith an change to the status of the information initiall pro!ided6 as and #hen the information changes$ *t is
t4e supplier7s responsiility to ensure t4at t4e information reflected on t4e #uppliers Re$ister is
correct and up to date at all times$ #uppliers must ensure t4at t4ey furnis4 t4e Department 6it4 any
updates to or c4an$e of information pertainin$ to an2in$ details as and 64en t4e c4an$e occurs.
3.8" #upplier Performance Monitorin$
Suppliers that ha!e registered onto the Suppliers Register #ill /e continuousl monitored for their performance on
#or. a#arded to them / DPW$ This continuous monitoring process #ill form the /asis to e!aluate Supplier
performance #hich #ill ha!e an impact on future #or. opportunities #ith the Department$
3.9" Confidentiality
All information pro!ided / suppliers for registration purposes #ill remain confidential and #ill onl /e of use /
DPW unless other#ise re"uired / la#$
3.:" 14ere to otain Application forms
1.6.1) Availability of Application orms
Application %orms can /e do#nloaded from DPW #e/site &http:77###$pu/lic#or.s$go!$8a7%orms$asp($
Application forms can also /e collected at DPW 4ead 5ffice and Regional 5ffices$
9o fa)ed or e-mailed applications #ill /e accepted$ 5nl original and signed copies of application #ill /e
accepted$ Suppliers ma not alter the Application %orm in an #a$

Page 2 of 12
1.6.2) Application form submissions
The applications forms for registration onto the Suppliers Register #ill /e processed at DPW 4ead 5ffice$
Suppliers should therefore ensure that the su/mit their Application %orms to the address /elo# 5R su/mit it
to their local Regional 5ffice:
Postal Address 0and Delivery
The Director-'eneral
Department of Pu/lic Wor.s
Pri!ate -ag :;<
Pretoria
0001
Attention: Deput Director: Supplier Register

(Note: Post application form by Registered Mail)
The Deput Director: Supplier Register
Department of Pu/lic Wor.s
+'5 -uilding = 9orth Wing 6 Room 12;
Supplier Register 4elpdes.
+nr -osman and >ermuelen Streets
Pretoria
0002
Re$ional +ffice Contact Numer
-loemfontein Regional 5ffice &0<1( ?00-@1027@1?2
+ape To#n Regional 5ffice &021( ?02-2A11
Dur/an Regional 5ffice &031( 31?-11<1712<2
Bohannes/urg Regional 5ffice &011( 113-;2?A
Cim/erle Regional 5ffice &0<3( @3@-<2217<2@<
,ma/atho Regional 5ffice &01@( 3@?-A331
9elspruit Regional 5ffice &013( 1<3-;3<2
Polo.#ane Regional 5ffice &01<( 2A3-@0127@0;2
Port Dli8a/eth Regional 5ffice &0?1( ?0@-2001
Pretoria Regional 5ffice &012( 310-<1<@
Emtata Regional 5ffice &0?1( <02-1010710;0
1.6.!) Support at "#W
An "ueries regarding registration can /e directed to:
0elpdes2: &012( 331-2A2? or &012( 331-21@1

3.;" Criteria for Re$istration
Suppliers that do not meet the responsi!e criteria ma not "ualif to /e registered onto the Supplier Register until
full registration re"uirements are met$
The Responsi!e +riteria for suppliers to /e registered onto the Supplier Register is stated /elo#:
Responsi!e +riteria for Suppliers for 'eneral 'oods and Ser!ices:
Supplier should ha!e a !alid Phsical -usiness Address
Supplier should ha!e a !alid Postal Address
Supplier should ha!e a !alid Telephone7+ellular 9um/er
Supplier should ha!e a !alid %a) 9um/er &5ptional(
Supplier should su/mit a -usiness Profile together #ith the Application %orm for +onsulting and Professional
Ser!ices
Supplier should pro!ide the Department of Pu/lic Wor.s #ith !alid -an.ing details &Company <an2
#tatement"
o Personal /an.ing details #ill not /e accepta/le e)cept in the case #here the supplier is a Sole Trader
Supplier should su/mit an 5riginal !alid Ta) +learance +ertificate
o Personal Ta) +learance +ertificates #ill not /e accepta/le e)cept in the case #here the supplier is a
Sole Trader
'" *MP+RTANT -.*D,)*N,#
'.3" -eneral
Dnsure that all applica/le sections in the Application %orm are completed as incomplete Application %orms #ill not
/e processed for registration onto the Supplier Register$
>erification of information pro!ided / suppliers ma /e chec.ed against third part sources such as SARS6 +FP+6
&etc(
Default Receiver of Contracts: The contact person that #ill recei!e notifications from the Department of Pu/lic
Wor.s
Tenderer. Page ) of 12
Page 3 of 12
Default Receiver of <ids: The contact person indicated #ill recei!e notification of -ids !ia e-mail or sms &please
select the preferred option(
Tenderer. Page ( of 12
Page ? of 12
2$2( Fmportant fields to complete
2$2$1( +ontact Person
Please indicate one &1( indi!idual that the Department of Pu/lic Wor.s should contact pertaining to -ids
and7or +ontracts$
2$2$2( Tpe of %irm
Please ensure the appropriate documentar proof pertaining to our tpe of %irm is attached and su/mitted
together #ith the Application %orm$
Please !ie# /elo# for the re"uired documentar proof:
F$ Partners4ip: +ertified cop of Partnership Agreement
FF$ #ole Proprietor: +ertified cop of !alid South African Fdentit Document
FFF$ Pulic Company re$istered in terms of t4e #A Companies Act: +ertified cop of +ertificate of Fncorporation of
companies &+,1(
F>$ Close Corporation re$istered in terms of t4e Closed Corporation Act: +ertified cop of %ounding Statement
+C1 or amended %ounding Statement &+C2( for ++2s
>$ Private Company re$istered in terms of t4e #A Companies Act: +ertified cop of +ertificate of Fncorporation of
companies &+,1(
>F$ Trust: +ertified cop of Trust deed or other founding document
>FF$ +t4er: Please pro!ide appropriate documentar proof
2$2$3( Shareholder75#ner Fnformation
Please complete all information for e!er shareholder75#ner listed on the form #ho has e"uit
o#nership in the firm$
Should the space pro!ided in this section not /e enough for the re"uired information6 please ensure that ou
ma.e a cop of this section6 complete it and su/mit it together #ith the Application %orm$
2$2$?( Su/3ect to su/-regulation <&3( and 7or ;&3(6 points must /e a#arded to a tenderer for attaining ----DD status
le!el contri/utor$
$
Tenderer. Page * of 12
Page < of 12
2$2$<( +ommodit +ategories
#uppliers s4ould not tic2 !=" items or services 64ic4 t4ey cannot provide. N.< #uppliers are allo6ed
to tic2 one !3" commodity only.

'.'.:" #uppliers Maintenance: <an2in$ *nformation Details
Anne>ure ( !#uppliers Maintenance and <an2in$ details". Please ensure t4at details furnis4ed in t4is
form are correct and t4at t4is Form is stamped y t4e Firm7s an2. T4is information 6ill e used y
t4e Department s4ould it need to ma2e payments to your Firm.
,nsure t4at t4is document !Anne>ure (" is sumitted to Finance section of DP1 to$et4er 6it4
relevant returnale documents.
#uppliers s4ould ensure t4at t4ey furnis4 t4e DP1 6it4 any updates to or c4an$e of information
pertainin$ to an2in$ details as and 64en t4e c4an$e occurs.
Anne>ure ( 6ill e issued to suppliers only 64en t4ey transact 6it4 t4e Department.
2$2$1( Details of person&s( authori8ed to act on /ehalf of the %irm
This section re"uires that suppliers pro!ide details pertaining to the indi!idual that the %irm authori8ed to
su/mit and sign the application form on their /ehalf$
Should the %irm authori8e more than one indi!idual to su/mit and sign the Application %orm on their /ehalf6
please ensure that ou ma.e a cop of this section6 complete it and su/mit it together #ith the Application
%orm$
2$2$@( Declaration7+ommissioner of 5aths
This section ser!es as a confirmation that the information pro!ided is true and correct and must /e signed
accordingl$
Tenderer. Page + of 12
Page ; of 12
3. F*RM7# <A#, DATA: !Compulsory"
3.3 Name of Firm:
3.' Tradin$ As:
3.( 0oldin$ Company Name:
3.8 Firm Re$istration Numer:
&Fnsert ++ num/er6 +ompanies Act num/er6 etc$(
3.9
TYP, +F F*RM !Tic2 applicale o> and
provide documentary proof":
Close corporation re$istered in terms of t4e Close
Corporation Act? 3@A8 !Act no :@ of 3@A8"
Pulic Company B!Pty" )imitedC re$istered in terms of
t4e #A Companies Act? 3@;( !Act no :3 of 3@;("
includin$ Companies incorporated under Art '3
#ole proprietor
Partners4ip
Private Company re$istered in terms of t4e #A
companies Act? 3@;( !Act no :3 of 3@;(" includin$
Companies incorporated under Art 9( !"
Trust
+t4er: &Specif(
3.: Telep4one Numer:
3.; Fa> Numer:
3.A <usiness P4ysical Address:

To6n:
3.@ Postal Address:

Postal Code:
3.3D
*ndicate t4e Province 64ere t4e aove FirmE<ranc4 is located:
,astern Cape Free #tate -auten$ F6aGulu&Natal )impopo
Mpumalan$a Nort4 1est Nort4ern Cape 1estern Cape
3.33 Date Firm ,stalis4ed:
3.3' /AT Re$istration Numer:
3.3( Firm 1esite Address:
3.38
Ta> Clearance Certificate Numer: Ta> Certificate ,>piry Date:
Ta> Certificate Approved Date:
'. C+NTACT P,R#+N D,TA*)#: !Complete for at least t6o Persons 5 Preferaly Mana$ement" !Compulsory"
C+NTACT P,R#+N 3 C+NTACT P,R#+N '
'.3 Contact Name:
'.' %o Title:
'.( Receiver of Contracts: Yes No Yes No
'.8 Receiver of <ids: Yes No Yes No
'.9 Telep4one Numer:
'.: Fa> Numer:
'.; Cellular Numer:
'.A ,&Mail Address:
Tenderer. Page , of 12
Page 1 of 12
#uHect to su&re$ulation 9!("? points must e a6arded to a tenderer for attainin$ <&<<,, status level contriutor in accordance 6it4 t4e tale elo6:
<&<<,, #tatus )evel of Contriutor Numer of Points !ADE'D system"
3 'D
' 3A
( 3:
8 3'
9 A
: :
; 8
A '
Non&compliant contriutor D
A ma>imum of 'D points may e allocated in accordance 6it4 su&re$ulation !'" of t4e PPPFA Re$ulations of 'D33.
T4e points scored y a tenderer in respect of t4e level of <<<,, contriution contemplated in su re$ulation !'" must e added to t4e points scored for price as
calculated in accordance 6it4 su re$ulation !3"
#uHect to re$ulation ;? t4e contract must e a6arded to t4e tenderer 64o scores t4e 4i$4est total numer of points.
(. R,F,R,NC,# !)ist 9 contractsEproHects? 64ic4 your Firm 4as een en$a$ed in for t4e last ' years"
Contract Description )ocation Client
Client Telep4one
Numer
Contract Amount
Completed E
,>pected
Completion
Date

Any reference to words Bid or Bidder herein and/or in any other documentation shall be construed to have the same meaning as the words Tender or Tenderer. Page - of 12
Page @ of 12
8. PR+/*NC,# 10,R, -++D# E #,R/*C, CAN <, PR+/*D,D: !Compulsory & Complete detail in Anne>ure3 for t4e I+nly certain To6nsJ selection."
9. C+MM+D*TY CAT,-+R*,#: !Compulsory & #elect E #pecify Commodity Cate$ories and Commodity #u Cate$ories from Anne>ure '"
:. #.PP)*,R MA*NT,NANC, 5 #.PP)*,R MA*NT,NANC, AND <ANF*N- D,TA*)#: !Compulsory & Complete details as per Anne>ure ("
Any reference to words Bid or Bidder herein and/or in any other documentation shall be construed to have the same meaning as the words Tender or Tenderer. Page . of 12
Page A of 12
;. D,TA*)# +F P,R#+N!#" A.T0+R*G,D T+ ACT +N <,0A)F +N T0, F*RM !Mandatory"
R,#+).T*+N +F +1N,R#ED*R,CT+R#E M,M<,R#EPARTN,R#

R,#+).T*+N of a meeting of the -oard of GDirectors 7 ,em/ers 7 Partners7 5#ners of:
___________________________________________________________________________
___________________________________________________________________________
&$egally correct full name and registration number of the %nterprise& if applicable)
4eld at ______________________________________________ &#lace)
5n _________________________________________________ '"ate)
R,#+)/,D t4at:
1$ The %irm su/mits an application to the Department of Pu/lic Wor.s for registration on DPWHs Supplier Register$
2$ G,r7,rs7,s: ____________________________________________________________________
in Ghis7her +apacit as: __________________________________________ &#osition in the %nterprise)
and #ho #ill sign as follo#s: ___________________________________________________________

/e6 and is here/6 authorised to sign an documents and7or correspondence in connection #ith and relating to the
Application %orm as #ell as to sign an +ontract6 and an and all documentation on /ehalf of the %irm.
Name Capacity #i$nature
1
2
3
?
<
;
The bidding enterprise hereby absolves the Department of Public Wors from any liability !hatsoever that may arise as a result of this
document being signed
Note: D9TDRPRFSD STA,P
1. N". (his resolution must be signed by all the
"irectors ) *embers ) #artners of the +idding
%nterprise
2. ,n the event that the paragraph 2 cannot be
complied -ith& the resolution must be signed by at
least .1/ of "irectors ) *embers ) #artners of the
+idding %nterprise
!. "irectors ) *embers ) #artners of the +idding
%nterprise may also appoint a person to sign this
document on behalf of the +idding %nterprise -ho
by his signature -arrants that he has been duly
authori0ed. 'Attach resolution)
1. Should the number of "irectors ) *embers)#artners
e2ceed the space available above& additional
names and signatures must be supplied on a
separate page
Tenderer. Page 1% of 12
Page 10 of 12
A. D,C)ARAT*+N:
- completing this application form6 the %irm declares that:
10$1 All the information supplied in this application is true and correct$
10$2 The %irm #ill6 #ithout protest su/mit itself to procedures instituted / the Department of Pu/lic Wor.s$
10$3 The %irm #ill6 if re"uested to do so suppl further information and documentar e!idence for scrutin$
10$? The %irm #ill update their registration particulars #hene!er a significant change in their details occurs$
10$< The %irm ac.no#ledges that an false information pro!ided can lead to dis"ualification from the Supplier
Register and /eing listed on Department of Pu/lic Wor.s non-preferred supplier list$
10$; The %irm ac.no#ledges that it can /e penali8ed for poor performance as the department deems necessar$
Fs there an relationship /et#een our organi8ation and an Department of Pu/lic
Wor.s emploeesI Jes 9o
Ff es6 please specif nature of relationship and name of person
%amil %riend -usiness Partner
%ull 9ame:
%ull 9ame : %ull 9ame :
10$1 RDTER9A-*D D5+E,D9TS &+ertified copies are accepta/le( &+ompulsor(
'eneral: Jes 9o 97A
10$1$1 Documentar Proof of %irm2s Registration &Refer to 2$<$?(
10$1$2 >AT Registration +ertificate
10$1$3 Ta) +learance +ertificate &5riginal and !alid for a minimum of 12 months(
10$1$? PSFRA +ertificate &Applica/le to suppliers in the Securit Fndustr(
10$1$<
+ertificate of Accepta/ilit from ,unicipalit &Applica/le to suppliers pro!iding %ood
and +atering Ser!ices(

10$1$; ,edical +ertificate &%or Disa/ilit Status(
10$1$1
Accreditation +ertificate &Applica/le to suppliers pro!iding computer soft#are and
hard#are(

10$1$@ ----DD +ertificate
10$1$A -usiness Profile
10$1$10 *ist of To#ns #here 'oods and Ser!ices can /e Supplied &Anne)ure 1(
10$1$11 +ommodit +ategories &Anne)ure 2(
10$1$12 Supplier ,aintenance: -an.ing Fnformation Details &Anne)ure 3(
10$1$13 Declaration of interest
Page 11 of 12
Duly aut4oriKed to si$n on e4alf of: 333333333333333333333333333333333333333333333333333333'4ame of irm)
The undersigned #ho #arrants that he 7 she is dul authori8ed to do so on /ehalf of the %irm6 confirms that the contents
of the application are #ithin m personal .no#ledge and are to the /est of m /elief /oth true and correct$
#i$nature Full Name Capacity Date
@. C+MM*##*+N,R +F +AT0#:
Signed and s#orn to /efore me at _____________________________________________ &#lace(
on this the ______________________ da of _____________________ / the Deponent6 #ho has ac.no#ledged that
he7she .no#s and understands the contents of this Affida!it6 that it is true and correct to the /est of his7her .no#ledge
and that he7she has no o/3ection to ta.ing the prescri/ed oath6 and that the prescri/ed oath #ill /e /inding on his7her
conscience$
+ommissioner of 5aths ______________________ 9ame: _____________________________
Signature ___________________________
Stamp
Note: All pa$es of t4is Affidavit must e initiated y ot4 t4e Deponent and t4e Commissioner of +at4s.
Page 12 of 12

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PA-23: Application for registration on the Supplier Register

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