SECURITY SERVICES/PRODUCTS SUPPLIERS
VETTING & DATABASE REGISTRATION FORM
1. Please write legibly and put all the information required.
2. Kindly complete the questionnaire in full.
3. An administrative fee of R100.00 is charged by the Department per Supplier’s registration form & must be paid at the
Cashier’s Office, Revenue Section on the Ground floor at Natalia Building, Pietermaritzburg.
4. The receipt from the payment of the administrative fee as indicated above must be affixed to the registration form &
submitted together with the relevant certified documents required as indicated on page 7 of the form).
5. Completed forms are to be delivered to Head Office Security Services Integrity Management Unit, Mrs C Louw.
6. If there are any changes to the information provided in this application form, it is your obligation to inform the
Department of Health Security Services Unit within seven (7) working days of such change.
7. Incomplete data & failure to provide proof of payment of the administrative fee will invalidate this form.
8. It is essential that all relevant parts of this document are fully completed, at which stage you will be subjected to a
security screening process which will determine your acceptance as an authorized and vetted Security Supplier to
the KwaZulu-Natal Department of Health
9. The KZN Department of Health reserves the right to verify and confirm all the information provided in this application
form. The Department of Health may request additional information during the verification process.
10. Please ensure that each page is initialled by the duly authorized representative.
11. All information provided will be classified as Strictly Confidential.
Business Enterprise / Company Details
Business Legal Name (as per SARS/CIPC)
Business Trade Name
Company Registration Number (CIPC)
Y Y Y Y / /
Sole Proprietor Registration Number (ID, etc.)
Y Y M M D D
Income Tax Reference Number
VAT Registration Number (if applicable)
PAYE Registration Number
SDL Registration Number
UIF Registration Number
PSIRA Company Registration Number:
KZN Prov. Treasury Suppliers’ Database Registration Number:
K Z N
Type of Business Enterprise (please the relevant box)
Close Corporation (cc)
Private Company (Pty) Ltd
Public Company (Ltd)
Section 21 Company
Date Business established
DD / M M / Y Y Y Y
How many years has your Organization been in business as a contractor/supplier?
How many years has your Organization been in business under its present business name?
Certified copy of CIPC Business Certificate attached (please relevant box)
Original SARS Tax Clearance Certificate attached (please relevant box)
Certified Copy of PSIRA Registration Certificate attached (please relevant box)
Original PSIRA Clearance Certificate attached (please relevant box)