SUPPLIER DATABASE FORM

							                                                                                                                                             Office of the Principal
                                                                                                                                             5 Ubla Avenue
                                                                                                                                             (Off Princess of Wales Terrace)
                                                                                                                                             Parktown, Johannesburg
                                                                                                                                             South Africa
                                                                                                                                             Private Bag 70500
                                                                                                                                             Houghton, 2041
                                                                                                                                             www.cjc.co.za
                                                                                                                                             E-mail: info@cjc.co.za
                                                                                                                                             Telephone: (011) 484 1388
                                                                                                                                             Facsimile: (011) 643 7358


            APPLICATION TO BE LISTED ON CJC’S DATABASE FOR THE
                      SUPPLY OF GOODS AND SERVICES

Name of Company
Company / Close Corporation
Registration Number



Physical Address




Postal Address



Telephone Number

Fax Number

E-mail Address

Contact Person



Names of Owner(s) / Directors



                                                                             Women
Percentage Ownership of HDI’s
                                                                             Disabled
Number of women and disabled                                                 Women Employed
employed and/or own the Company                                              Disabled Employed
Income Tax Reference Number
PAYE Employer’s Registration Number
(if applicable)


   Alexandra Campus                          Ellis Park Campus                         Highveld Campus                           Parktown Campus
   Cor. Canning & Ninth Road, Alexandra      25 Currey Street, Doornfontein            39 Ashburton Street, Riverlea             5 Ubla Avenue, Parktown
   Tel: (011) 882 9763 Fax: (011) 882 3305   Tel: (011) 402 2990 Fax: (011) 402 2991   Tel: (011) 474 2080 Fax: (011) 473 2321   Tel: (011) 643 8421 Fax: (011) 643 1020
 TYPE OF GOODS / SERVICES TO BE PROVIDED / RENDERED (Categorise type of services that you may
 offer per group of items. Also indicate expected delivery period where necessary)
                              GROUP                                                      TYPE OF GOODS/SERVICE                                       DELIVERY PERIOD
 BUILDING /CONSTRUCTION AND WORKS
 LANDSCAPING
 SIGNAGE
 ARCHITECTURAL SERVICES
 OTHER



In the event that preference points are claimed for HDI members by consortia/joint ventures, the following
information must be furnished in order to be entitled to the points claimed in respect of the HDI member.

 Name of HDI member (to be consistent with                                                      Percentage (%) of the contract value managed or
 above paragraph)                                                                               executed by the HDI member




    NB: This document MUST accompany the Company Profile which must be sealed and hand delivered at our
    offices.




     Alexandra Campus                          Ellis Park Campus                            Highveld Campus                           Parktown Campus
     Cor. Canning & Ninth Road, Alexandra      25 Currey Street, Doornfontein               39 Ashburton Street, Riverlea             5 Ubla Avenue, Parktown
     Tel: (011) 882 9763 Fax: (011) 882 3305   Tel: (011) 402 2990 Fax: (011) 402 2991      Tel: (011) 474 2080 Fax: (011) 473 2321   Tel: (011) 643 8421 Fax: (011) 643 1020