DE 43

Private Bag x19, Sunny Pretoria, 0007, Tel: (012) 444 4000,
Trevenna Office Campus, 70 Meintjies Street, Pretoria

SUPPLIER REGISTRATION FORM FOR 2011/12

APPLICATION FOR REGISTRATION ON THE DEPARTMENT OF ENERGY

SUPPLIER DATABASE

Applicant Name: ________________________________________________

Applicant Contact Person: ________________________________________

Contact Person Tel. No: __________________________________________

NEW APPLICATION (tick) UPDATED APPLICATION (supplier number)

For office use only

Received on: YY ______ MM ______ DD ______ at HH ______ MM _______

Received by (print full name) ___________________________________________

Signature: ________________________

Verified on: YY ______ MM ______ DD ______ at HH ______ MM _______

Verified by (print full name) ___________________________________________

Signature: ________________________

Captured on: YY ______ MM ______ DD ______ at HH ______ MM _______

Captured by (print full name) ___________________________________________

Signature: ________________________
 IMPORTANT NOTES

Please read carefully

COMPLETING THE DEP ARTMENT OF ENERGY SUPPLIER

REGISTRATION FORM

Business Opportunities – Please note that Registration on the Department of Energy Supplier Database
does not guarantee business opportunities. All procurement will be subject to the procurement and tender
policy of the Department and applicable legislation.

Mandatory fields – Certain fields and documentation are mandatory to certain business types. Please
ensure that all fields which are mandatory to your business type have been completed failure to which the
application won’t be processed. If a field is not applicable to your business type clearly mark it as N/A.
(Not Applicable)

Required documentation – Please refer to the Document Requirement Checklist to determine the
mandatory supporting documentation required by your business type. Please ensure that all copies of
Mandatory documents (certified copies, where applicable) are attached, Failure to which the application
won’t be processed.

Completion of Questions – Please answer all questions, as incomplete forms will not be processed.
Clearly Mark with an X, to state Yes, No or N/A to the questions asked.

Certified Documents – Please ensure that a Commissioner of Oaths has certified your Company
Registration Document and other required documents.

Processing of Registration Forms – Your completed Registration Form will be processed, and, once
verified, will be captured as an approved supplier on the department’s database. Suppliers will not be
notified whether the application was approved or not, but will be advised of the outcome if requested.

Amendments – Please notify the department immediately of any changes to the verified information
submitted.

Forms that are not legible or incomplete will not be processed on the database.

Verification – verification of the information supplied will be performed against third party sources such as
SARS, DTI, CIDB, etc. The Department of Minerals and Energy reserves the right to request additional
information or documentation regarding this Registration form and request to conduct an audit when
necessary.

Queries – Should you have any queries or if you require assistance completing the registration form,
please contact the Department’s Supply Chain Management (SCM).unit on 012 444 4371/4373.

Completed registration forms and supporting documentation must be handed in at Department of

Energy, Head Office or at the Regional Offices
(Please refer to contact list)

PLEASE KEEP COPIES OF THE COMPLETED REGISTRATION FORM AND ALL

DOCUMENTATION SUBMITTED
 A. CONTACT DETAILS

1. SUPPLIER DETAIL (Mandatory)

Supplier Registered Name:

Supplier Trading Name (If different from

Registered Name)

Company registration number:

Company or Firm income tax reference

number:

Vat Registration Number

Date on which firm was first established:

(i.e. original founding date)

Telephone Number:

Fax Number:

Physical Address:

Postal Address:

Postal Code:

Nearest town:

Province

2. Please attach the following documents (Mandatory)

Original valid tax clearance certificate

Original banking confirmation letter

Certified company registration

Certified identified document(s) of all owner(s) / shareholder(s)

3. CONTACT PERSON DETAILS (Mandatory)

Name:
Job Title:
Telephone Number:
Fax Number:
Cellular Number:
E-Mail Address:
Notification: (E-mail or SMS)
Comment:
Default Receiver of Contracts: (Y/N)
Default Receiver of Tenders: (Y/N)

4. ALTERNATIVE CONTACT PERSON DETAILS (Mandatory)

Name:
Job Title:
Telephone Number:
Fax Number:
Cellular Number:
E-Mail Address:
Notification: (E-mail or SMS)
Comment:
Default Receiver of Contracts: (Y/N)
Default Receiver of Tenders: (Y/N)

B. COMPANY/FIRM DERTAILS

5. TYPE OF FIRM
(Tick applicable box) (Mandatory)

One person business / sole trader

Partnership/ Consortium
Close corporation registered in terms of the SA Close Corporations Act
Public/Private company registered in terms of the SA Companies Act
Non Profit company registered in terms of the SA Companies Act
Trust as defined in the Income Tax Act
Cooperative Society as defined in the Co – operatives Act
Government/ State Owned Enterprise/ Constitutional Entity
Other: (Specify)
6. BANK DETAILS (No Personal Account information) (Mandatory)

Name of Bank:
Name of Branch:

Branch Code:

Name of Account Holder:

Account Number:

Account Type: (Tick applicable box):

Cheque Savings Transmission B Bond Subscription Share Not in Use

DATE STAMP OF BANK

BANK ACCOUNT
PARTICULARS

CERTIFIED AS CORRECT Mark the applicable entity: Address to send the payment stub:

Employee

Periodical Employee

Garnishee Beneficiary

Supplier

NB. Please ensure that your bank details have been verified by the bank, and also attach a
cancelled Cheque or bank acknowledgement letter.

7. TO BE COMPLETED ONLY IF FIRM IS AN AFFIRMABLE BUSINESS ENTERPRISE (Tick

applicable box and complete relevant percentages)

Black owned (At least 50.1%)

Black Enterprise (At least 25.1%)
Black woman owned (At least 25.1%)
Other Woman
HDI
Disabled
SMME
Total 100%
8. SMME STATUS OF YOR ENTERPRISE: (Mandatory)

Please use the table below 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
A. Sector (OR LESS) (OR LESS) (property excluded) (millions)
Mediu Very Mediu Very Mediu Very
m Small Small Micro m Small Small Micro m Small Small Micro
Agriculture 100 50 10 5 4 2 0.4 0.15 4 2 0.4 0.1
Mining and
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 and Motor
trade 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
Repair/Allied
Services 100 50 10 5 30 15 3 0.15 5 2.5 0.5 0.1
Communications/IT 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 Agents 100 50 10 5 50 25 5 0.15 8 4 0.5 0.1

9. SMME status of your enterprise

(Please the relevant box according to SMME table below) (Mandatory)

Micro
Very Small
Small
Medium
Large

10. DIRECTORS / OWNERS DETAILS

(Complete table for each Director/ Owner) (Mandatory)

Position / Telephone Percentage

Person Name: ID Number: Citizenship
Title: Number: Share Holding:
11. MANAGEMENT AND BUSINESS DECISIONS (Mandatory)

Identify by name, HDI status and length of service, those individuals in the firm
(including owners and non-owners) responsible for day-to-day management and business decisions.
NAME STATUS
(YES/NO)

Population
LENGTH OF SERVICE

Disability
(YEARS)

Woman
Priority

HDI
FINANCING
DECISIONS
CHEQUE SIGNING
SIGNING & CO-
SIGNING FOR LOANS
ACQUISITION OF
LINES OF CREDIT
SURETIES
MAJOR PURCHASE
OF ACQUISITIONS
SIGNING CONTRACTS

12. LIST A MAXIMUM OF FIVE CONTRACTS, WHICH YOUR FIRM HAS

BEEN ENGAGED IN

EXPECTED
CONTRACT CONTRACT COMPLETION
LOCATION CUSTOMER/CLIENT
DESCRIPTION AMOUNT (MONTH AND
YEAR)

C. COMMODITY INFORMATION

13. COMMODITY CATEGORIES

(Please select / specify the five(5) commodity that you can supply from the commodity structure)
(Mandatory)

14. REGIONS WHERE GOODS / SERVICE CAN BE PROVIDED

(Mark with X) (Mandatory)

Cape town Welkom

Durban Witbank

Pretoria Rustenburg

Kimberly Port Elizabeth

Johannesburg Polokwane
Klerksdorp
 D. CHECK LIST

15. Indicate whether the following documents are attached

General: (Y/N)
Original valid tax clearance certificate (mandatory)
Company registration certificate (mandatory)
Original bank confirmation letter
Certified ID copies of all owners / Shareholders (mandatory)
Companies owners and share certificates and agreements (Optional)

E. DECLARATION

16. The undersigned who warrants that he / she is duly authorized to do so on behalf of the Firm, confirms
that the contents of the application are within my personal knowledge and are to the best of my believe
both true and correct.

By completing this application form, the Firm declares that:

16.1 It agrees to conform to the requirements of the Supplier Register as set out in this document.

16.2 The Firm agrees to abide by the Procurement Policy.

16.3 All the information supplied in this application is true and correct.

16.4 The firm will, without protest, submit itself to procedures instituted by the department of Mineral
Resources

16.5 The Firm will, if requested to do so, supply further information and documentary evidence for
scrutiny.

a. The Firm will update their registration particulars whenever a significant change in their details
occur and, in any event, at intervals of two years.

Duly authorized to sign on behalf of: ________________________________________________

Signature Name Capacity Date