Supplier Registration NB: All fields with a star (*) are mandatory and need to be completed before submitting the form 1 Company Registration Details2 Supplier Detail3 Declaration of Interest Are you registered with the Central Supplier Database for Government?*YesNoUpload Central Supplier Database Report Summary*MAAA Number*Company Name*Trading Name*Reg. No.*e.g. 2004/140566 /23VAT No.Income Tax No.*Number of full-time employeesCompany Details:Email* WebsiteTel area codeTelephone No.Fax No.Toll free No.Address:Postal AddressCity / TownPostal CodePhysical AddressCity / TownPostal CodeClassification of business* ISO Listed Importer Services Manufacturer Repairer Black owned Distributor Exporter Sales Classification of Company/Supplier* ISO Listed Importer Services Manufacturer Repairer Black owned Distributor Exporter Sales Contact Person DetailsTitle*First Name*Surname*Cell No*Work No.Fax No.Position*Email* Declaration of interest 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 bidder or his/her authorised representative declare his/her positionin relation to the evaluating/adjudicating authority where- the bidder 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. In order to give effect to the above, the following questionnaire must be completed and submitted with the bid.Full Name of bidder or his or her representative:*Identity number*Position occupied in the CompanyPlease selectDirectorTrusteeShareholderMemberCompany Registration Number*Tax Reference Number*VAT Registration NumberThe names of all directors / trustees / shareholders / members, their individual identity numbers, tax reference numbers and, if applicable, employee / PERSAL numbers must be indicated*Are you or any person connected with the bidder presently employed by the state?*YesNoName of person / director / trustee / shareholder/ member*Name of state institution at which you or the person connected to the bidder is employed*Position occupied in the state institutionAny other particularsIf you are presently employed by the state, did you obtain the appropriate authority to undertake remunerative work outside employment in the public sector?*YesNoAttach proof of such authority to the bid document*Furnish reasons for non-submission of such proofDid you or your spouse, or any of the company’s directors trustees / shareholders / members or their spouses conduct business with the state in the previous twelve months?*YesNoFurnish particulars*Do you, or any person connected with the bidder, have any 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?*YesNoFurnish Particulars*Are you, or any person connected with the bidder, aware of any relationship (family, friend, other) between any other bidder and any person employed by the state who may be involved with the evaluation and or adjudication of this bid?*YesNoFurnish Particulars*Do you or any of the directors / trustees / shareholders / members of the company have any interest in any other related companies whether or not they are bidding for this contract?*YesNoFurnish particulars* Proprietors/Shareholders/Partners/Sole Proprietors/Trustees/OwnersNameEmailID NumberCellularShare %HDIWEDisabled Yes Add personRemove personPlease list all owners (as listed above) Certify correct information*I AcceptI, 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 Name*Accepted Date Date Format: DD slash MM slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.