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SECURITY SERVICES/PRODUCTS SUPPLIERS
VETTING & DATABASE REGISTRATION FORM
____________________________________________________________________________________________________________________________________
INSTRUCTIONS:
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
9
VAT Registration Number (if applicable)
4
PAYE Registration Number
7
SDL Registration Number
L
UIF Registration Number
U
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)
Sole Proprietor
Partnership
Section 21 Company
Consortium
Trust
Foreign Company
Joint Venture
Other (specify)
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)
Yes
No
Original SARS Tax Clearance Certificate attached (please relevant box)
Yes
No
Certified Copy of PSIRA Registration Certificate attached (please relevant box)
Yes
No
Original PSIRA Clearance Certificate attached (please relevant box)
Yes
No
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Address & Contact Details
Company Contact Person
Designation
Business Physical Address: Business Postal Address:
Postal Code:
Postal Code:
Office Telephone Number(s)
/
-
/
-
Office Facsimile Number
/
-
Cellular Number
/
-
E-mail Address (main)
E-mail Address (alt)
Website Address
Control Room Address & Contact Details
Telephone Number
/
-
Physical Address
Postal Code
Emergency/ After Hours Contact Details
Primary Contact Person
Designation
Contact Number
/
-
Alternative Contact Person
Designation
Contact Number
/
-
Quality Management System Details
Is your Organization quality registered? (QMS) (please relevant box)
Yes
No
If Yes, please provide details:
Name of QMS Authority:
If No, do you have a written Quality Policy and Document? (please relevant box)
Yes
No
Quality Policy and Document copy attached (please relevant box)
Yes
No
Details of Key Personnel in your Business
Designation Full Names Identity Numbers
Managing Director
Y Y M M D D
General Manager
Y Y M M D D
Financial Director
Y Y M M D D
HR Manager
Y Y M M D D
Health & Safety Officer
Y Y M M D D
Security Supervisor
Y Y M M D D
Certified ID document copies of above individuals attached (please relevant box)
Yes
No
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Total Number of Employees
Cate
g
or
y
of Personnel Male Female Total
Management
Administration
Professional
Skilled Qualified Staff
Skilled Unqualified staff
Part-time staff
Total Staff Establishment
Financial Information
What is your Business average annual turnover (sales)
Name of Account Holder
Financial Institution/Bank
Branch Name Branch Code
Account Number
Account Type (please relevant box)
Current Savings Transmission
Other (please specify)
Contact Person
Designation
Business Physical Address: Business Postal Address:
Postal Code:
Postal Code:
Office Telephone Number
/
-
Office Facsimile Number
/
-
Cellular Number
/
-
E-mail Address (main)
Proof of Banking Details stamped by the Bank attached (please relevant box)
Yes
No
Insurance
Do you have insurance applicable to your Organisation? (please relevant box)
Yes
No
If Yes, please indicate the applicable types of insurance listed below (please relevant box)
Product Liability
Professional Indemnity Public Liability
Indicate the insurance value in respect of each applicable type of insurance?
Product Liability
Professional Indemnity
Public Liability
Proof of Product Liability Insurance as indicated above (please relevant box)
Yes
No
Proof of Professional Indemnity Insurance as indicated above (please relevant box)
Yes
No
Proof of Public Liability Insurance as indicated above (please relevant box)
Yes
No
Skills Development & Training
Do you have a staff development plan? (please relevant box)
Yes
No
If Yes, please list the programs in place:
Name of Registration Body:
Skills Development & Training Registration proof attached (please relevant box)
Yes
No
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Accreditation Information
Registration Categories for Suppliers approved contractor. Please indicate which services you are able to provide with
direct labour; Do not include sub-contracted services:
Services offered through sub-contractors should be included under sub-contracted section, specifying the
additional services.
Please note that the categories are provision of services and supply of security consumables and equipment.
Please the relevant boxes.
Supply the relevant documentation where required.
Information must be able to demonstrate your competency in relevant category.
Security
Perimeter Fencing
Security Illumination
Access Control
Access Control Security Systems
Guarding
Guarding (Armed)
Armed response
Alarms/ Monitoring Systems
CCTV Systems
Security Control Room Console
Radio’s (incl. 2 Way Radio’s)
Other Communication
Other Security Systems
Executive Protection (VIP)
Events Security
Cash in Transit Management
Metal Detectors (incl. Hand Held)
Security Advising & Consulting
Threat Risk Assessments
Investigations
Fire Safety Consultant
Fire Fighting
Fire Alarms
Fire Sprinklers/ Smoke Detectors
Fire Hydrants, Hoses, Extinguishers
Security Uniforms
Security Training & Development
Safety Restraint Systems
Sub-Contracted – Please specify:
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Geographic Coverage
Please indicate on the following map, the geographical areas of the Province in which you are prepared to work.
Also please provide an estimate of the radius from your Company address where you are willing to work
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Geographic Coverage (cont.)
District Distance District Distance
Ugu (DC 21) Umgungundlovu (DC 22)
Uthukela (DC 23) Umzinyathi (DC 24)
Amajuba (DC 25) Zululand (DC 26)
Umkhanyakude (DC 27) Uthungulu (DC 28)
Ilembe (DC 29) Sisonke (DC 43)
eThekwini
Regional Office Details
Do you have Regional Offices in your Organization? (please relevant box)
Yes No
If YES, please list each Regional Office:
Site Name:
Contact Person
Designation
Physical Address
Province Postal Code
Office Telephone Number
/
-
Office Facsimile Number
/
-
Cellular Number
/
-
E-mail Address (if available)
If you have more than one (1) Regional Office, please use a separate sheet with the above details.
Other Details
Do you share any facilities? (please relevant box)
Yes
No
If YES, with which company do you share facilities?
Provide postal address:
Physical Address
Province Postal Code
Which facilities are shared?
Which Professional Bodies are you
required to register or affiliated to?
Your registration no.?
Year in which you were last registered?
Certified copy of Registration Certificate attached (please relevant box) Yes No
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Declaration
I hereby agree that, in the event of false, incorrect or misleading information being provided in this declaration, the
Head of Department shall have the right to:
Recover any losses or damages sustained by the Department under such agreement;
Restrict the Supplier from further business with the Department depending on the materiality of the
misrepresentation and the degrees of prejudice suffered.
Signature
Full Names of Representative:
ID No.
Y Y M M D D Date DD/ M M / YYYY
(DULY AUTHORISED TO SIGN FOR AND ON BEHALF OF THE ABOVE ENTITY)
Commissioner Of Oath Information
Signature
Place Commissioner
Of Oath Stamp Here
Name
Rank
Date
Submission of Documents
This application form must be completed by Security Service Providers/Suppliers in order to register on the Department
of Health Vendor Management System.
In order for your application to be processed, the following documentation MUST accompany th
is form, failing which
your application will not be considered for registration on the system.
Documents Required
A
ttached
Proof of payment of the administrative fee in the form of a receipt
Certified copy of your Business Registration documents if you are incorporated as a Company,
Close Corporation, Co-Operative, Partnership, etc. with CIPC (prev. CIPRO)
Certified copies of ID documents of all Directors, Shareholders, Members, Partners, Sole
Proprietors, Management, etc.
Original, valid Tax Clearance Certificate as issued by SARS
Original, valid PSIRA Clearance Certificate as issued by PSIRA
Certified copy of PSIRA Business Registration Certificate
Proof of approved Membership status with South African Security Association
Original, valid letter from your Bank verifying the banking details of your business.
Proof of registration with UIF & the Workman’s Compensation Fund (COIDA)
Proof of Skills Development & Training Registration
Proof of Public Liability, Product Liability & Professional Indemnity insurance
Details of Joint ventures (incl. certified copy of JV agreement)
Certified copy of the Quality Policy and Document
Certified cop
y
of Firearm Competenc
y
Certificate
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.
Please ensure that each page is initialled by the duly authorized representative.
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