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Hs Application Form Registration On The Western Cape Human Settlements Facilitators Database

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27 views4 pages

Hs Application Form Registration On The Western Cape Human Settlements Facilitators Database

Uploaded by

kikinuere
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HSC 33/2013/2014

APPLICATION FOR REGISTRATION ON THE WESTERN


CAPE: DEPARTMENT OF HUMAN SETTLEMENTS
FACILITATORS DATABASE

Name of Service Provider:

__________________________________________________________________

Name of Authorized representative:

__________________________________________________________________

Tel No: _________________________________________

For office use only

Received on: DD ______ MM ______ YY ______

Received by (print full name)

_____________________________________________________________

Signature: _________________ Reference Number: _______________

Service Provider Registration Code: ________________

Verified by Chief Directorate/ Professional Services:

Name: _________________ Signature: _____________ Date: __________

Page 1
Enhanced Peoples Housing Process (EPHP) Facilitator Database Application Form
SUPPLIER DETAILS
Registered name of the company

Trading name of the company

Company/ Close Corporation registration Western Cape Supplier Database reference


number: number:

Business start date: Fax Number:

Telephone Number: E-mail Address:

Web Address Business Contact Telephone Number:

Name of Contact Person: Contact numbers Cell:

Business Physical Address: Postal Address:

Contact Person: Contact Person:

OWNERSHIP & EQUITY (NB: Percentage distribution of equity)


African Coloured Indian White Total
Men

Women

People with
Disabilities
Youth

Page 2
WHAT IS THE FIRM’S AVERAGE ANNUAL TURNOVER (EXCL. VAT)?

R____________________________________

INDIVIDUALS IN MANAGEMENT OF FIRM (INCLUDE OWNERS AND NON-OWNERS)


RESPONSIBLE FOR DAY-TO-DAY MANAGEMENT AND BUSINESS DECISIONS

NAME RACE GENDER DISABILITY LENGTH OF


SERVICE (YEARS)

FACILITATORS REFERENCES

LIST THE THREE LARGEST PROJECTS COMPLETED BY YOUR FIRM IN THE LAST FOUR
YEARS
Name of Project Name of Project Name of Client & Value of Project
Completed Manager & Telephone Telephone no
no

LIST THE CURRENT PROJECTS THAT YOUR FIRM IS INVOLVED IN


Name of Current Project Name of Project Name of Client & Value of Project
Manager & Telephone Telephone no.
no.

Page 3
LOCALITY
Please indicate with () areas where your business currently operates:

West Coast …. Metro …. Eden ….

Central Karoo …. Overberg …. Cape Winelands ….

ATTACHMENTS (COMPULSARY):

Please attach certified copies of the following documents TICK


 Fully Completed Contractors Questionnaire
 ID Documents of owners
 Company Registration Documents
 Shareholders agreements/certificates for companies
 Proof of Western Cape Supplier Database Registration

I hereby declare that the above information is correct at the time of completion. I declare
that I (the undersigned) have the appropriate authority to furnish the above mentioned
information on behalf of the company.

I hereby declare that the information provided, is to the best of my knowledge true and
correct and furthermore give consent rights to allow the WCG Department of Human
Settlements to verify all the information provided

For and on behalf of the Date


company

Capacity of signatory (position


held in Company)

Page 4

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