Supplier Application Form - Val de Vie

All Supplier Application 1/5Supplier Application FormAll supplier information will be treated strictly confidential.Application forms to be in writing (email / fax / mail / hand delivered).Registered Name:Trading Name:Registration No:VAT Reg. No:Income Tax No (if notVAT registered):Limited (Pty) Ltd PartnershipType of BusinessSolePrivate IndividualProprietorshipPhysical Address of Trading Business (Domicilia citandi et executandi)Building:Street:City:Postal Address:Building:Street/PO Box:City:Contact Details: (include the area code)CompanyRepresentative:Fax:Telephone:Cellular:E-mail:Banking Details:Account Holder:Bank Name:Branch Name & Code:Account No:Telephone No:Years at BankReason:Postcode:(If less than 5 years, list previous bank below, and reason for change inbank)2012-08-13 Confidential Version 5

All Supplier Application 2/5Directors/Owners: (Please indicate name and residential address of majoritydirectors/owners)Surname:First Name:Identity NumberAddressCityShareholding (%)Surname:First Name:Identity NumberAddressCityShareholding (%)Surname:First Name:Identity NumberAddressCityShareholding (%)1.1 Supplier ProfileNature of servicesPlease provide a description of services/products offered.Gross Turnover per Annum?R0 – R1milR1mil – R2milR2mil – R5milAbove R5milInsurances:What Public Liability Insurance do you hold?Insurance Company?Value?ExcessRDo you hold Professional Indemnity Cover?Insurance Company?Limit of LiabilityRR2012-08-13 Confidential Version 5

All Supplier Application 3/51.2 CommercialName 3 commercial references / referees of previous projects:Company/NameTelephone:Company/NameTelephone:Company/NameTelephone:1.3 QualityDoes your business operate a Quality Management System covering the product /service applying forY/NProvide detailsHas your Quality Management System been assessed and certified by anyNational/Internationally recognized accredited body?Y/NIf Y, please provide a copy of the certificate1.4 SafetyAre you registered with Compensation of Occupational Injuries and Disease Act (COID)Y/NReg #The Supplier, completing this form, agrees to:i. Bear full responsibility for ensuring that the provisions of the OccupationalHealth and Safety Act, Act 85/1993 (OHS Act) and its Regulations asamended and current at the time of any WORKS PROCURED are properlydispose of and implemented in respect of the areas designated for WORKSPROCURED.ii. Explicitly undertake to ensure compliance with all Safety, Health andEnvironmental legal requirements.iii. Ensure an updated and complete Safety Plan and File with a site and taskspecific Risk Assessment shall always be available on the premises where anyWORKS PROCURED is conducted.iv. Ensure a supervisor and/or an assistant supervisor shall at all times beavailable and present on the premises whilst WORKS PROCURED is inprogress.v. Ensure a Fall Protection Plan is communicated, implemented and available onsite and that all employees shall adhere to it at all times.vi. Ensure that a valid Letter of Good Standing is available on site.vii. Adhere to all health and safety rules and emergency procedures of anycompany part of the Val de Vie Group of Companies.viii. Fully & completely indemnifies any company part of the Val de Vie Group ofCompanies, its employers, directors or agents of whatsoever nature in theevent of any and all claims arising.2012-08-13 Confidential Version 5

All Supplier Application 4/51.5 Required Supporting DocumentationCopies of the following documents are to be included in your application (whereapplicable):1.5.1 EME’s (Exempt Micro Enterprises) ID Documents of owners / partners Letter from accountant/auditor confirming turnover Copy of COID registration certificate ( if applicable ) Public Insurance Certificate, Public Indemnity Cover details Tax Clearance Certificate(Current, valid Certificate) VAT Registration(VAT103 DOCUMENT) BEE status/rating confirmation Proof of Business Address(Latest Municipal Account) List of contactable customer references Registration certificate pertaining to relevant industry e.g. ECB ( ElectricalContractors Board ) Any other registration certificate pertaining to your relevant industry, e.g.ECB (Electrical Contractors Board) An original cancelled cheque or stamped letter from the bank, verifyingbanking details. Please note that any changes to bank details in future will besubject to the same requirement.1.5.2 Companies - EME documents as well as Registration Documents Certificate from External Auditors confirming turnover. Company Organogram, showing holding and subsidiary company(s), indicateownership and shareholding that this company holds in other companies Companies claiming Black Empowerment are to submit documents thatprovide proof of ownership and management by Black Individuals.1.6 Conditions for ApprovalVal de Vie will, after evaluation and approval by designated staff of theapplication, notify suppliers on the acceptance of their application andGroup’s Approved Contractors List. At this point the supplier will be issued avendor number.Val de Vie reserves the right to verify all claims made by the supplier in thisapplication.Changes in control of firm after registration in supplier database should becommunicated to Val de Vie within 30 days following the change.The Health and Safety Contract between Employer and Contractor iscompleted in full, signed and dated.1.7 Applicants DeclarationI declare that: The information furnished in this form is true and correct in every respect All specialized work will be performed by qualified personsApplicantSignature2012-08-13 Confidential Version 5

All Supplier Application 5/5NameDateProposer (Val de Vie)SignatureNameDateApprover, on behalf of the Val de Vie Group of CompaniesSignatureNameDateU:\!Finances\Suppliers\Supply Chain\Vendor Form\H_F_SC_Supplier Application_06.docx2012-08-13 Confidential Version 5