1

ANNOUNCEMENTTO ALL SUPPLIERS: THE STATE SECURITY AGENCY (SSA) INVITES SUITABLY QUALIFIED AND EXPERIENCED SUPPLIERS TO EXPRESS THEIR INTEREST IN SUPPLYING GOODS AND/OR SERVICES IN VARIOUS REGIONS

SSA recognises the need to stimulate local trade in the regions/provinces where it operates. Suppliers are hereby invited to express their interest in being considered as approved suppliers/service providers on the SSA Suppliers’ Database. All previously registered suppliers are required to reapply due to the overhaul of the database.

In order to comply with National Treasury instructions, the State Security Agency is required to develop a database of suppliers who are to be selected on a rotational basis for the procurement of goods and services up to the value of R500,000.00 per transaction. The purpose of this database is to give prospective suppliers an equal opportunity to submit quotations to the State Security Agency.The goods and services that may be required by the SSA include, but are not limited to:

Suppliers/service providers who are interested in supplying or providing services may request an application form by contacting the SSA or by downloading the forms (www.ssa.gov.za). Completed original application forms may be posted, couriered or hand delivered with a company profile to: Postal Address Physical Address State Security Agency State Security Agency Private Bag X87 Musanda Complex (Joe Nhlanhla Str) Pretoria R50 (Delmas Road) 0001

Enquiries can be directed to: Ms Annelie Snyders (012) 427 4617 annalies@ssa.gov.za Ms Nandi Mfeya (012) 427 4612 mfeya@ssa.gov.za

Ms Leoni Seyfferdt (012) 427 4344 leonis@ssa.gov.za

NB: A security competency check is conducted on all service providers before their services are utilised. SSA reserves the right to obtain any outstanding information it deems necessary and to appoint and contract service providers once deemed to offer the best service and to comply with all requirements and to monitor their performance. SSA further reserves the right to request or require of any supplier/service provider to undergo security clearance/vetting and to contract with only vendors that obtain the appropriate security clearance level.

Audio-, voice-, visual aids, devices and surveillance listening equipment

Information and communication technology (ICT): computer hardware, software, services and consumables

Chemicals and laboratory equipment Electromagnetic shielding and devices Locksmith equipment Track and tracing equipment, devices Global system for mobile (GSM) monitoring interception

equipment Global positioning system (GPS) devices, equipment, tracers

and trackers Surveillance/Covert equipment: RF transmitters, electronic

and phone bugs, body wires, voice changer and other. Telephone wiretaps, RF jammers, bug detectors, camera

detectors Portable HF/UHF/VHF/low-band two-way radios, search and

analysis equipment LED fiberscope devices Security equipment, iris, biometric, vaults, safes, access

control, closed-circuit TV (CCTV), etc. Unmanned Aerial Vehicle (UAV). Armour equipment Asset insurance/ Assurance

Polygraph equipment: lie detectors and voice stress analysis equipment, devices.

Explosive Ordnance Disposal (EOD) solutions Encryption equipment and services (all types: voice, video,

data) Labour saving and printing: press, layout, digital devices,

equipment, copiers, printers, 3D press, duplication machines, etc.

Vehicle, fleet related and management services, equipment, parts, servicing, panel beating, towing, etc.

Research and development Professional services Catering equipment and services Satellite telephony, antennae, services, equipment,

bandwidth, tracking Language, transcription and translation services Property appraisal, valuations, Construction: professional and project management

services General: catering, stationery, consumables,

accommodation and travel, venue bookings, subscriptions, books/publications/journals, fuel and gas.

Charter/Freight/Transportation: land, sea and air Property Valuers

2

SUPPLIER REGISTRATION APPLICATION FORM

New Application Yes No

INSTRUCTIONS

The Supplier Registration Application form serves to apply to be registered on the SSA’s Suppliers’ Database.Section A Company DetailsSection B Bank DetailsSection C Ordering DetailsSection D Account DetailsSection E Type of EnterpriseSection F Reference DetailsSection G SafetySection H Commodity/Services Section I Conditions of PurchaseSection J Declaration of Interest and Related PartiesSection K Documentation Required

Certain fields and documents are mandatory to certain business types. Please ensure that all fields that are mandatory to your business type are completed and those that are not are clearly marked N/A. Only fully completed forms submitted together with all required substantiating documentation are considered.

Processing of Registration – Your completed registration will be processed once verified, after which it will be approved or rejected. The letter of confirmation of registration will be dispatched to the work address supplied. Once your registration is in the SSA database, your details will be accessible to the purchasing officers/buyers of SSA. Formal registration as a creditor of SSA shall only be done on placement of the first official order.

Business Opportunities – Please note that registration on the SSA Suppliers’ Database does not guarantee business opportunities. Inclusion in a database does not in any way guarantee business from SSA for any person, company, services provider or supplier, etc. All procurement will be subjected to the Procurement- and Tender Policies of SSA.

When Consortiums/Joint Ventures are making an application, each party must separately submit a completed SSA-SCM1 form (together with all required substantiating documentation).

A company profile may accompany the registration form but will not be accepted as substitute for the application form.

It should be noted that the SSA reserves the right to accept or reject any application. A BBBEE Status level verification certificate must be submitted in order to qualify for preference points.

TAX CLEARANCE CERTIFICATE REQUIREMENTS The consideration of an application is subject to the applicant providing a tax clearance certificate or proving

that satisfactory arrangements have been made with South African Revenue Service (SARS) to meet the applicant’s tax obligations.

The original tax clearance certificate must be submitted. Failure to submit the original and valid tax clearance certificate will result in the invalidation of the application. Certified copies of the tax clearance certificate are not acceptable.

When consortia/joint ventures/sub-contractors are involved, each party is required to submit a separate tax clearance certificate.

The tax clearance certificate requirement also applies to foreign suppliers. Tax clearance certificates are obtained from any SARS office nationally.

Any arrangements or dispute of whatever nature with SARS needs to be supported by written proof from SARS for consideration.

Incomplete or incorrectly submitted application forms will not be considered. All supplier information submitted will be treated in the strictest confidence.

SCM 1

3

Where the financial risks are deemed to be high, suppliers that meet all the requirements will be requested to submit most recent financial statements. These financial statements will be evaluated and qualifying suppliers will be loaded on the database.

PLEASE STATE TYPE OF GOODS OR SERVICE TO BE PROVIDED:(or Description of Principal Business)

WHAT IS THE PRIME SECTOR IN WHICH BUSINESS IS CONDUCTED?

SECTION A: COMPANY DETAILS

Registered Name of Enterprise

Trading Name of Enterprise

How long has the enterprise been in business?Title, Initials & Surname: (In the event of a sole proprietor)Previous Name(s) of Enterprise (if applicable)

Enterprise Registration Number/ CIPRO

VAT Registration Number

Postal Address

Postal Code

4

Physical Address

Postal Code

E-Mail Address

Telephone Number - Fax Number -

Website

LIST ALL PARTNERS, PROPRIETORS AND SHAREHOLDERS. (Attach your own list if the space provided is inadequate).

Name Position Occupied ID Number Citizens Date of Ownership

PLEASE INDICATE (X) THE GEOGRAPHICAL AREAS WHERE YOUR BUSINESS IS WILLING AND CAPABLE OF SUPPLYING GOODS OR SERVICES TO THE SSA:

Gauteng KwaZulu-Natal Western CapeMpumalanga Free State Eastern CapeNorth West Northern Cape Limpopo

5

SECTION B: BANK DETAILS (See attached banking details form)Name of Enterprise

Name of Account

Bank

Branch Name

Branch Number

Account Number

Type of Account Current Account Savings Account Transmission Account

SSA Payment Terms: 30 days after receipt of invoice and statement

SECTION C: ORDERING DETAILS

Contact Person

Telephone Number 1

- Telephone Number 2

-

Fax Number - May orders be placed by e-mail? Yes No

E-Mail Address

6

SECTION D: ACCOUNT DETAILS

Contact Person

Telephone Number 1

- Telephone Number 2

-

Fax Number - May payment advice be forwarded by e- mail?

Yes No

E-Mail Address

SECTION E: TYPE OF ENTERPRISE (Tick the appropriate box.)

Public Company Private Company Partnership Close Corporation

Other

If you have ticked “Other”, please specify ...

In terms of the definitions of enterprises in the Codes of Good Practice on BBBEE, is your business a/n:

Exempt Micro-Enterprise (EME, annual turnover less than R5 million)?

Qualifying Small Enterprise (QSE, annual turnover between R5 million and R35 million)?

Large Business (annual turnover above R35 million)?

BBBEE Contribution LevelA valid BBBEE certificate from the South African National Accreditation System (SANAS)-accredited verification agency or proof of exemption by the registered auditor/accounting officer is to be provided.

How many full-time employees does your enterprise employ?% Black Male Ownership % Black Female Ownership% White Female Ownership

7

SECTION F: REFERENCES

Details of Your Reference (if applicable)?

Contact Name: Contact Tel/Cell Number

Contract:

Assignment Details

SECTION G: SAFETY

Do you conduct your business in compliance with the requirement of the Occupational Health and Safety Act?(OHS Act No. 85 of 1993) (Yes/No) …………………………………………………………………………

Are you registered and in good standing with the Compensation Commissioner? (Compensation for Occupational

Injuries and Diseases Act No. 130 of 1993) (Yes/No) …………………………………………………………………………….

If Yes, kindly attach a copy of a valid letter of Good Standing. Please note that this is compulsory for all maintenance and building contractors.

DISPOSALS:Auctioneering Services, waste disposal, sales, etc.

Clothing and textilesFurnitureGeneral (SPECIFY)Medical WastePropertyRecycling (Paper, tyres, etc.) (environmentally friendly)Scrap MetalVehiclesWaste disposal

8

SECTION I: CONDITIONS OF PURCHASE

IMPORTANT CONDITIONS PERTAINING TO PURCHASE ORDERS

1. The Seller shall bear the risk of goods being damaged, lost or destroyed until delivery to the SSA is effected and receipt thereof acknowledged.

2. The Seller shall make provision for suitable packing, preservation and delivery in all quotations. Unless otherwise stated all packing containers and packing material shall become the property of the SSA upon delivery.

3. Unless otherwise stated, all goods shall be new and of the best quality. Goods shall be subject to approval by the SSA at all times. A Seller is under obligation to supply suitable materials and/or quality goods. This obligation is to be honoured even if the SSA made no objection, inspected the said goods or took delivery thereof.

4. Should the Seller be unable to fulfil said obligations in terms of the order, the SSA is to be advised to this effect in writing, in which case the SSA reserves the right to cancel the order and to purchase the goods from another supplier. The Seller may be obligated to compensate the SSA for any differences in cost.

5. Inasmuch as delivery of the goods may require the Seller or an authorised agent to enter the SSA premises, the Seller shall ensure that precautions necessary to protect life and property anywhere on the SSA premises are taken, and the Seller shall be liable to the SSA for injury to any person, or damage to SSA property caused by or incidental upon negligence or default on the part of the Seller or authorised agent.

6. SSA’s order number must appear on the delivery note and invoice . Any invoices and delivery notes without an order number will be ignored and returned to the supplier company. Invoices without order numbers are considered to be private agreements with individuals.

7. No alteration to an order may be made without the written approval of the Supply Chain Unit/Purchasing Division (SSA).

8. Part deliveries will be accepted only under exceptional circumstances. Payment thereof will be made only when ALL goods/services have been delivered.

9. SSA reserves the right to cancel any order in the event of goods not being delivered or services rendered by the agreed date.

10. It is a firm SSA requirement that all prospective suppliers complete the Supplier Registration Application form in full to be registered on its database.

11. All invoices must be forwarded to the address printed on the Purchase Order (PO).

12. Central Stores: No deliveries will be accepted outside delivery hours, unless prior arrangements are made with the Stores whose personnel can be contacted at:Pretoria: (012) 426 2500Delivery Times: Monday to Friday: 07:30 to 16:00.

13. Should the Seller accept the PO, or should the order not be returned within 10 days of the date thereof, it shall be assumed that the conditions as set out in the paragraphs above are binding.

14. Payment will be made thirty days after receipt of original invoice and statement.

15. NB: A security competency check may be conducted on all service providers before a PO is issued or services utilised.

16. SSA reserves the right to: obtain any outstanding information deemed necessary in the selection of a supplier. appoint and contract service providers and monitor their performance once they are deemed to offer the best service and

comply with all requirements. request or require any supplier/service provider to undergo security clearance/vetting and to contract with only vendors that

obtain the appropriate security clearance level.

9

SECTION J: DECLARATION OF INTEREST AND RELATED PARTY INTEREST BY SUPPLIER

DECLARATION OF INTEREST BY A SUPPLIER WISHING TO CONDUCT BUSINESS WITH THE SSA

1. Any legal person, including persons employed by the state1, or persons having a kinship with persons employed by the state, including a blood relationship, may make an offer or offers in terms of this invitation to bid (includes a price quotation, advertised competitive bid, limited bid or proposal). In view of possible allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons employed by the state, or to persons connected with or related to them, it is required that the applicant or his/her authorised representative declare his/her position in relation to the evaluating/adjudicating authority where: the applicant is employed by the state; and/or the legal person on whose behalf the bidding document is signed, has a relationship with persons/a person who

are/is involved in the evaluation and or adjudication of the bid(s), or where it is known that such a relationship exists between the person or persons for or on whose behalf the declarant acts and persons who are involved with the evaluation and or/adjudication of the bid.

2. In order to give effect to the above, the following questionnaire must be completed and submitted with the bid.

2.1 Full Name of Applicant or His or Her Representative: ………………………………………………………………....

2.2 Identity Number: ………………………………………………………………………………………………………….…

2.3 Position Occupied in the Company (Director, Trustee, Shareholder): ……………………………………………..…

2.4 Company Registration Number: ……………………………………………………………………..…………….…..…

2.5 Tax Reference Number: ……………………………………………………………………………….…………………..

2.6 VAT Registration Number: ………………………………………………………………………………........................2.6.1 The names of all directors/trustees/shareholders2/members, their individual identity numbers, tax reference

numbers and, if applicable, employee/persal numbers must be indicated in paragraph 3 below.

2.7 Are you or any person connected with the applicant YES / NO presently employed by the state?2.7.1 If so, furnish the following particulars: Name of person/director/trustee/shareholder/member: ………………….....………………………………………….. Name of state institution at which you or the person:

connected to the applicant is employed : .………………………………………………………………..……………...

Position occupied in the state institution: ………………………………………………………………………………Any other particulars:

1 ‘State’ means –a) any national or provincial department, national or provincial public entity or constitutional institution within the

meaning of the Public Finance Management Act, 1999 (Act No. 1 of 1999);b) any municipality or municipal entity;c) provincial legislature;d) national Assembly or the national Council of provinces; ore) Parliament.

2 ‘Shareholder’ means a person who owns shares in the company and is actively involved in the management of the enterprise or business and exercises control over the enterprise.

10

…………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2.7.2 If you are presently employed by the state, did you obtain YES / NOthe appropriate authority to undertake remunerative work outside employment in the public sector?

2.7.2.1 If yes, did you attached proof of such authority to the bid YES / NOdocument?(Note: Failure to submit proof of such authority, whereapplicable, may result in the disqualification of the bid.

2.7.2.2 If no, furnish reasons for non-submission of such proof:

…………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2.8 Did you or your spouse, or any of the company’s directors/ YES / NOtrustees/shareholders/members or their spouses conduct business with the state in the previous twelve months?

2.8.1 If so, furnish particulars:…………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2.9 Do you, or any person connected with the applicant, have YES / NOany relationship (family, friend, other) with a person employed by the state and who may be involved with the evaluation and or adjudication of this bid?

2.9.1 If so, furnish particulars.…………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2.10 Are you, or any person connected with the applicant, YES/NOaware of any relationship (family, friend, other) between any other applicant and any person employed by the statewho may be involved with the evaluation and or adjudicationof this bid?

2.10.1 If so, furnish particulars.…………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

2.11 Do you or any of the directors/trustees/shareholders/members YES/NO

11

of the company have any interest in any other related companies, whether or not they are bidding for this contract?

2.11.1If so, furnish particulars:…………………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

3. Full Details of Directors/Trustees/Members/ShareholdersFull Name Identity Number Personal Tax

Reference NumberState Employee Number/Persal Number

DECLARATIONI, THE UNDERSIGNED (NAME)………………………………………………………………………CERTIFY THAT THE INFORMATION FURNISHED IN PARAGRAPHS 2 AND 3 ABOVE IS CORRECT. I ACCEPT THAT THE STATE MAY REJECT THE BID OR ACT AGAINST ME IN TERMS OF PARAGRAPH 23 OF THE GENERAL CONDITIONS OF CONTRACT SHOULD THIS DECLARATION PROVE TO BE FALSE.

I ACCEPT AND ACKNOWLEDGE THAT SSA MAY TAKE FURTHER ACTION AGAINST ME, INCLUDING REMOVAL FROM SSA DATA BASE AND REJECT THIS APPLICATION SHOULD THIS DECLARATION PROVE TO BE FALSE.

I TAKE NOTE OF THE FACT THAT IF INCORRECT INFORMATION IS SUPPLIED, THE SSA RESERVES THE RIGHT TO CANCEL/TERMINATE ANY ORDER/CONTRACT PREVIOUSLY AWARDED TO THE APPLICANT.

THE SSA RESERVES THE RIGHT TO AUDIT ALL INFORMATION SUPPLIED ABOVE.

I certify that I am authorised to sign this form or to make this representation and acknowledge that I know and understand the contents of this declaration. I truly affirm that the contents of this declaration are true. NAME

………..………………………………………………………

SIGNATURE

……………………………………………………………….

CAPACITY under which this Registration Application form is signed in its entirety:

…………………………………………………………………

POSITION …………………………………………………………………………..

CONTACT DETAILS (Phone, Fax number and email address) ………………………………………………………………………….

………………………………………………………………………….

12

PLEASE RETURN THE COMPLETED DOCUMENTS AND SUPPORTING DOCUMENTS TO THE SUPPLY CHAIN UNIT AT THE FOLLOWING ADDRESS:

STATE SECURITY AGENCYSUPPLY CHAIN UNITPrivate Bag X87PRETORIA

SSA Headquarters MUSANDA COMPLEX (JOE NHLANHLA STREET) R50 Delmas Road, 0001

Enquiries may be referred to:Ms Annelie Snyders: (012) 427 4617 annalies@ssa.gov.za

Ms Nandi Mfeya: (012) 427 4612 mfeya@ssa.gov.za

Ms Leoni Seyfferdt: (012) 427 4344 leonis@ssa.gov.za

Further enquiries, compliments or complaints may be referred to: Procurement@ssa.gov.za

Enquiries regarding the Application Form or Registration may be directed to the address or contact details above between 07:30 and 16:00 from Mondays to Fridays.

SECTION K: DOCUMENTATION REQUIRED

PLEASE ATTACH CERTIFIED COPIES OF THE FOLLOWING DOCUMENTS:

1. Only original valid SARS clearance certificate

2. Valid Letter of Good Standing from Compensation Commissioner (OHS) (if applicable)

3. Signed and Bank-Stamped Confirmation of Banking Details Form/or Chief and Financial Officer (CFO) or the Chief Executive Officer (CEO) letter.

4. Cover letter citing relevant skills and experience signed by the Service Provider/Supplier Representative, including references.

5. Company Registration Documents (Select Relevant Form of Ownership, Including Point 1 4)

5.1 Sole Proprietors

Proprietor’s Proof of Identity Document

5.2 Close Corporations

Company Registration ( Certificate of Incorporation)

Founding Statement (CK1/CK2)

Proof of Identity (Member(s) ID/Passport Certified Copies)

13

Proof of Ownership (Certificate of Members’ Interest)

5.3 Private Companies

Company Registration (Certificate of Incorporation)(Registration Certificate)

Proof of Ownership (Share Certificate(s))

Proof of Identity (Shareholders ID/Passport)

Memorandum and Article of Association/Memorandum of Incorporation

5.4 Partnerships

Partnership Agreement

Proof of Identity (Partners’ ID/Passport)

5.5 Public Companies

Company Registration (Certificate of Incorporation) (Registration Certificate)

Memorandum and Article of Association/Memorandum of Incorporation

5.6 Business Trusts

Company Registration (Trust Agreement)

Proof of Ownership (Trust Details: Letter of Authority)

Proof of identity (Trustee’s ID/Passport)

5.7 Non-Profit Organisations

Company Registration (Certificate of Incorporation Section 21)

Proof of Ownership (Auditor’s Confirmation Letter – No Shareholding)

Proof of identity (Members’ ID/Passport)

ADDITIONAL DOCUMENTARY REQUIREMENTS

(All certified documents where applicable)

Comprehensive Company Profile.

Audited Financial Statements (To include the Income Statement, Balance Sheet and Cash Flow Statement for a

period of 2 years).

All Company Bank Account/s Details.

Three months Bank-statements

Letter from the Bank Indicating the Bank Credit Rating (Bank Code).

Contract Guarantees (If Applicable).

14

Name Change Certificate/Amended Founding Statement (If Applicable).

Proof of Directorship/Shareholding (And Changes, If Applicable).

Identity Documents of Directors/Members/Shareholders/Sole Proprietor (To be involved in the project).

Identity Documents and List of Employees/Contractors who require access to the premises. Employee

confirmation appointment letter.

Proof of BEE Compliance (Scorecard).

Name and Contact Details of Auditing/Accounting Firm.

List of Major Creditors, Contact Names and Contact Details.

Letters Declaring Members’ or Directors’ Involvement in Associated Businesses.

CIPRO Certificate-Company Registration Certificate with the Department of Trade and Industry.

Completed Supplier Application Form (Interview Report between Procurement and Supplier).

Three Letters of Good Standing (from the companies that did business with your Company).

All Relevant Industry Registration Information and Compliance Certificate (If Applicable)

15

SBD 0

SECURITY CLEARANCE REQUIREMENTS

It is a condition of bid that the successful bidder obtains a positive security clearance by undergoing and cooperating with the vetting officers who will conduct a vetting process on both the company and the individuals who will be involved in the project.

1. In order to meet this requirement, bidders are required to complete the attached forms in full:a.Declarationsb.Security Questionnaire for Security Clearance Purposes

2. The bidder must supply all documents as outlined in ‘Company document requirements’ with the proposal on or before the closing date or when called upon to do so within a specified period determined by the State Security Agency (SSA).

3. The level of security clearances will be determined by the SSA commensurately based on the nature of the project activities in which the employee will be involved.

4. The cost of obtaining suitable clearances is for the account of the vendors.

5. The vendors shall supply and maintain a list of personnel involved on the project, indicating their clearance status.

6. The default requirement on security clearance is ‘confidential’. Any other environment specified will have a ‘secret’ security clearance requirement.

7. Non-cooperation with the vetting officers may result in a Vendor being disqualified from the bidding and/or appointment process.

8. I/We agree that any action arising from this contract may in all respects be instituted against me/us and I/we hereby undertake to satisfy fully any sentence or judgement which may be pronounced against me/us as a result of such action.

I, THE UNDERSIGNED (FULL NAME)………………………………………………………………………………………CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS TRUE AND CORRECT.

I ACCEPT THAT, IN ADDITION TO CANCELLATION OF A CONTRACT, ACTION MAY BE TAKEN AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE

………………………………….. …………..…………………….……Signature Date

………………………………… …………………………………….Position Name of Bidder

16

CONFIRMATION OF BANKING DETAILS

TO BE COMPLETED BY COMPANY

ACCOMPANIED BY REQUEST ON LETTERHEAD OF COMPANY

REGISTERED NAME OF PERSON/COMPANY

ACCOUNT NUMBER

BANK NAME

BRANCH NAME

BRANCH CODE

FULL NAME OF REQUESTOR

SIGNATURE OF REQUESTOR

FOR COMPLETION BY BANK OFFICIAL

TO VERIFY THAT ACCOUNT NUMBER AND NAME OF COMPANY CORRESPOND WITH ACCOUNT DETAILS PROVIDED

FULL NAME OF BANK OFFICIAL

BRANCH

DATE

BANK STAMP: SIGNATURE OF BANK OFFICIAL

FOR OFFICIAL USE BY SSA FINANCE

CAPTURED BY VERIFIED BY

DATE DATE

APPROVED BY

DATE

17

SBD 8

DECLARATION OF BIDDER’S PAST SUPPLY CHAIN MANAGEMENT PRACTICES

1. This Standard Bidding Document must form part of all invited bids.

2. It serves as a declaration to be used by institutions in ensuring that when goods and services are being procured, all reasonable steps are taken to combat the abuse of the supply chain management system.

3. The bid of any bidder may be disregarded if that bidder, or any of its directors have:

a. abused the institution’s supply chain management system;b. committed fraud or any other improper conduct in relation to such system; orc. failed to perform on any previous contract.

4. In order to give effect to the above, the following questionnaire must be completed and submitted with the bid.

Item Question Yes No4.1 Is the bidder or any of its directors listed on the National Treasury’s database as companies or

persons prohibited from doing business with the public sector?(Companies or persons who are listed on this database were informed in writing of this restriction by the National Treasury after the audi alteram partem rule was applied.)

Yes No

4.1.1 If so, furnish particulars:

4.2 Is the bidder or any of its directors listed on the Register for Tender Defaulters in terms of section 29 of the Prevention and Combating of Corrupt Activities Act (No 12 of 2004)?To access this Register enter the National Treasury’s website, www.treasury.gov.za, click on the icon “Register for Tender Defaulters” or submit your written request for a hard copy of the Register to facsimile number (012) 326 5445.

Yes No

4.2.1 If so, furnish particulars:

4.3 Was the bidder or any of its directors convicted by a court of law (including a court outside of the Republic of South Africa) for fraud or corruption during the past five years?

Yes No

4.3.1 If so, furnish particulars:

4.4 Was any contract between the bidder and any organ of state terminated during the past five years on account of failure to perform on or comply with the contract?

Yes No

4.4.1 If so, furnish particulars:

CERTIFICATION

I, THE UNDERSIGNED (FULL NAME)…………………………………………………………………………………………..CERTIFY THAT THE INFORMATION FURNISHED ON THIS DECLARATION FORM IS TRUE AND CORRECT.I ACCEPT THAT, IN ADDITION TO CANCELLATION OF A CONTRACT, ACTION MAY BE TAKEN AGAINST ME SHOULD THIS DECLARATION PROVE TO BE FALSE.

……………………………………………………………... ………………………………………………………..Signature Date

…………………………………………………………..…. …………………………………………………..……Position Name of Bidder