Application for Authentication (Circle Appropriate Selection Where

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posted:: 12/18/2009
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HARMONY GOLD MINING COMPANY LIMITED P O Box 2 RANDFONTEIN 1760 Procurement Department Tel : (011) 278-0008 Harmony Gold Mining Company Limited (Registration number 1950/038232/06)

Vendor Application – (Circle Appropriate Selection Where Applicable)
1. Full Company Name

Trading Name

Company Type

SOLE PROPRIETOR

PARTNERSHIP

CLOSED CORPORATION PRIVATE COMPANY PUBLIC COMPANY CLUB 4. 5. 6. Company Registration Number VAT Registration Number Physical Address NGO NON-PROFIT

Postal Address

8. 9.

Contact Fax Number Company Website Address

10. Contact Person (Sales/Procurement) 11. Contact Telephone Number 12. Contact E-mail Address

Directors:

P T Motsepe* (Chairman), G P Briggs (Acting Chief Executive), F Abbott*, F T de Buck*, Dr D S Lushaba*, CM L Savage*, M J Motloba*, N V Qangule , C Markus*, A J Wilkens, J A Chissano*# *Non - Executive; Mozambiquen
#

Secretary: MP Van Der Walt Registration Number : 1950/038232/06

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HARMONY GOLD MINING COMPANY LIMITED P O Box 2 RANDFONTEIN 1760 Procurement Department Tel : (011) 278-0008 Harmony Gold Mining Company Limited (Registration number 1950/038232/06)

13. Contact Person (Financial) 14. Contact Telephone Number 15. Contact E-mail Address 16. Trade Reference 1 a. b. c. d. Name Position Company Contact Telephone Number

17. Trade Reference 2 a. b. c. d. Name Position Company Contact Telephone Number

18. Trade Reference 3 a. b. c. d. Name Position Company Contact Telephone Number

19. Annual Turnover – 12 Months to date 20. Number of Employees 21. Number of Sites 22. Nature of Main Business

23. Nature of Main Products/Services

Directors:

Secretary: MP Van Der Walt Registration Number : 1950/038232/06

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HARMONY GOLD MINING COMPANY LIMITED P O Box 2 RANDFONTEIN 1760 Procurement Department Tel : (011) 278-0008 Harmony Gold Mining Company Limited (Registration number 1950/038232/06)

Please attach the following documents to this application (without them the application will not be processed ): • • • • • • • Company Letterhead reflecting the directors names BBBEE Verification Certificate Original cancelled or Used Cheque Original Valid Tax Clearance Certificate in Respect of Tenders/Good Standing Indemnity Signed by Each Director/Member/Partner Certified copies of Identity Documents Risk Assessment

As a person authorised to sign on behalf of the company, I hereby submit this company for authentication with Harmony Gold Mining Company Limited (Harmony). I hereby authorise Harmony to possess confidential information on our company’s Directors/Members/Shareholders/Partners as well as business information. I furthermore authorise Harmony to keep record of confidential company and individual information regarding criminal background, credit record, risk profiles, technical ability and educational qualifications and/or any relevant information such as is usually kept on the Harmony database as a result of its assessments and enquiries. I also authorise Harmony to query public databases of information containing information on the company and its Directors/Members/Shareholders/Partners. I understand that it is a condition, that: • The information is furnished solely for the purpose of my proposed screening by Harmony. .

Signed at (Place) ___________________________ on (Date) _______________________

for (Company Name) _______________________________________________________

Initials and Surname:

____________________________________

Position in Company:

____________________________________

Signature:

____________________________________

*Please Note: Incomplete and/or unsigned applications will not be processed.

Directors:

Secretary: MP Van Der Walt Registration Number : 1950/038232/06

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HARMONY GOLD MINING COMPANY LIMITED P O Box 2 RANDFONTEIN 1760 Procurement Department Tel : (011) 278-0008 Harmony Gold Mining Company Limited (Registration number 1950/038232/06)

Broad Based Black Economic Empowerment Scorecard for Authentication
CORE COMPONENT ELEMENT CODE GENERIC WEIGHT <35m >5m SCORE GENERIC WEIGHT >35m SCORE

DIRECT EMPOWERMENT

OWNERSHIP MANAGEMENT CONTROL

BEE1100 BEE1200

25.00 25.00

20.00 10.00

HUMAN RESOURCE DEVELOPMENT

EMPLOYMENT EQUITY SKILLS DEVELOPMENT

BEE1300

25.00

15.00

BEE1400

25.00

15.00

INDIRECT EMPOWERMENT

PREFERENTIAL PROCUREMENT ENTERPRISE DEVELOPMENT RESIDUAL ELEMENT

BEE1500

25.00

20.00

BEE1600

25.00

15.00

BEE1700

25.00

5.00

BROAD BASED BEE SCORE TOTAL

BEE STATUS LEVEL

PROCUREMENT RECOGNITION LEVEL FOR AN ACCEPTED BEE RATING CERTIFICATE PLEASE CONTACT THE ASSOCIATION OF BEE VERIFICATION AGENCIES (ABVA) : 086 111 2282 / info@abva.co.za

Declaration By Company Representative: I hereby declare that the above summary is an accurate reflection of my company’s Broad Based Black Economic Empowerment Status, based on Bona Fide information supplied to the verification agent by our company at the time of assessment, which is free from material defects or misrepresentation.

Directors:

Secretary: MP Van Der Walt Registration Number : 1950/038232/06

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HARMONY GOLD MINING COMPANY LIMITED P O Box 2 RANDFONTEIN 1760 Procurement Department Tel : (011) 278-0008 Harmony Gold Mining Company Limited (Registration number 1950/038232/06)

Initials and Surname :

-----------------------------------------------------------------------------------------

Signed

-----------------------------------------------------------------------------------------

As a person authorized to sign on behalf of the company, I hereby submit this company for authentication with Harmony Gold Mining Company Limited (Harmony). I hereby authorize Harmony to possess confidential information on our company’s Directors/Members/Shareholders/Partners as well as business information. I furthermore authorize Harmony to keep record of confidential company and individual information regarding criminal background, credit record, risk profiles, technical ability and educational qualifications and/or any relevant information such as is usually kept on the Harmony database as a result of its assessments and enquiries. I also authorize Harmony to query public databases of information containing information on the company and its Directors/Members/Shareholders/Partners.

I understand that it is a condition, that: • The information is furnished solely for the purpose of my proposed screening by Harmony.

Signed at (Place) ___________________________ on (Date) _______________________

for (Company Name) _______________________________________________________

Initials and Surname:

____________________________________

Position in Company:

____________________________________

Signature:

____________________________________

*Please Note: Incomplete and/or unsigned applications will not be processed.

Directors:

Secretary: MP Van Der Walt Registration Number : 1950/038232/06

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HARMONY GOLD MINING COMPANY LIMITED P O Box 2 RANDFONTEIN 1760 Procurement Department Tel : (011) 278-0008 Harmony Gold Mining Company Limited (Registration number 1950/038232/06)

-endIndividual Indemnity Form (To be completed by each director/member/partner)
1. 2. 3. 4. 5. Initials and Surname Citizenship Identification Number Mode of Identification Director/Member/Partner of (Company Name)

Please attach a Certified Copy of Identity Document to this indemnity (without it the application will not be processed): As an individual, I hereby submit myself for authentication with Harmony Gold Mining Company Limited (Harmony). I hereby authorise Harmony to possess confidential information as well as business information relating to my own criminal record, credit profile and information related to my business activities. I furthermore authorize Harmony to keep record of confidential company and individual information regarding criminal background, credit record, risk profiles, technical ability and educational qualifications and/or any relevant information such as is usually kept on the Harmony database as a result of its assessments and enquiries. I also authorize Harmony to query public databases of information containing information relating to me as an individual. I understand that it is a condition, that: • The information is furnished solely for the purpose of my proposed screening by Harmony. • Harmony may pass on this information and or cede their rights as mentioned above to an agency concerned with the verification of this information to conduct enquiries and assessments and store information on their behalf. Should Harmony elect to do so, any such assessments by a third party will be for my own account. • On completion of the assessment Harmony will receive a copy of the report and a re-assessment will be conducted on an annual basis. Should vendor status be granted as a result of this assessment and subsequent assessments are unsuccessful, I understand that vendor status may be suspended or terminated altogether.

Directors:

Secretary: MP Van Der Walt Registration Number : 1950/038232/06

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HARMONY GOLD MINING COMPANY LIMITED P O Box 2 RANDFONTEIN 1760 Procurement Department Tel : (011) 278-0008 Harmony Gold Mining Company Limited (Registration number 1950/038232/06)

Signed at (Place) ___________________________ on (Date) _______________________

Initials and Surname:

____________________________________

Position in Company:

____________________________________

Signature:

____________________________________
*Please Note: Incomplete and/or unsigned applications will not be processed

Manufacturer's and Supplier's duty for health and safety:
Section 21 of the Mine Health and Safety Act, 29 of 1996, prescribes as follows in relation to the manufacturer's and supplier's duty for health and safety: 21. (1) Any person who (a) designs, manufactures, repairs, imports or supplies any article for use at a mine must ensure, as far as reasonably practicable (i) that the article is safe and without risk to health and safety when used properly; and (ii) that it complies with all the requirements in terms of this Act; (b) erects or installs any article for use at a mine must ensure, as far as reasonably practicable, that nothing about the manner in which it is erected or installed makes it unsafe or creates a risk to health and safety when used properly; or (c) designs, manufactures, erects or installs any article for use at a mine must ensure, as far as reasonably practicable, that ergonomic principles are considered and implemented during design, manufacture, erection or installation. 21-Negligent failure resulting in endangerment to a person at a mine is an offence. See s. 86. (2) Any person who bears a duty in terms of subsection (1) is relieved of that duty to the extent that is reasonable in the circumstances, if (a) that person designs, manufactures, repairs, imports or supplies an article for or to another person; and (b) that other person provides a written undertaking to take specified steps sufficient to ensure, as far as reasonably practicable, that the article will be safe and without risk to health and safety when used properly and that it complies with all prescribed requirements. (3) Any person who designs or constructs a building or structure, including a temporary structure, for use at a mine must ensure, as far as reasonably practicable, that the design or construction is safe and without risk to health and safety when used properly.

Directors:

Secretary: MP Van Der Walt Registration Number : 1950/038232/06

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HARMONY GOLD MINING COMPANY LIMITED P O Box 2 RANDFONTEIN 1760 Procurement Department Tel : (011) 278-0008 Harmony Gold Mining Company Limited (Registration number 1950/038232/06)

(4) Every person who manufactures, imports or supplies any hazardous substance for use at a mine must (a) ensure, as far as reasonably practicable, that the substance is safe and without risk to health and safety when used, handled, processed, stored or transported at a mine in accordance with the information provided in terms of paragraph (b); (b) provide adequate information about (i) the use of the substance; (ii) the risks to health and safety associated with the substance; (iii) any restriction or control on the use, transport and storage ofthe substance, including but not limited to exposure limits; (iv) the safety precautions to ensure that the substance is without risk to health or safety; (v) the procedure to be followed in the case of an accident involving excessive exposure to the substance, or any other emergency involving the substance; and (vi) the disposal of used containers which the substance has been stored and any waste involving the substance; and (c) ensure that the information provided in terms of paragraph (b) complies with the provisions of the Hazardous Substances Act, 1973 (Act No. 15 of 1973). 21(4)(c)-The Hazardous Substances Act provides for the control of substances which may cause ill health due to their toxic or flammable nature.

We acknowledge that we are aware of our obligations in terms of the above act and hereby undertake to abide by them

* FACSIMILIE OR AN ELECTRONIC VERSION OF THIS APPLICATION DOCUMENT WILL NOT BE ACCEPTED *
Checklist - For Harmony Gold Mining Company Limited use only 1. Company letter head reflecting the director/member/partner name/s 2. BBBEE verification certificate 3. Original – Cancelled or Used cheque 4. Original Valid Tax Clearance Certificate 5. Indemnity signed by each director/member/partner 6. Certified copies of identity document/s 7. Risk Assessment

Directors:

Secretary: MP Van Der Walt Registration Number : 1950/038232/06

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