2-Supplier Database Application Form

CLOSING DATE FOR APPLICATION
08 DECEMBER 2023 @ 11h00
Version October 2023

© GEMS
Annexures
Annexure “A” - Declaration of Interest Form

Annexure “B” - Declaration of Past Supply Chain Management Practices
Annexure “C” - Instructions for completing the Application Form
Abbreviations
B-BBEE Broad-Based Black Economic Empowerment

CIPC Companies and Intellectual Property Commission
CSD Central Supplier Database of the Government
DTIC Department of Trade, Industry and Competition of the Government
EME Exempted Micro Enterprise
ESD Enterprise and Supplier Development
GEMS Government Employees Medical Scheme
IRBA Independent Regulatory Board for Auditors
POPIA Protection of Personal Information Act
QSE Qualifying Small Enterprise
SANAS South African National Accreditation System
SARS South African Revenue Service
SMME Small, Medium and Micro Enterprise
VAT Value-Added Tax
2
SUPPLIER DATABASE APPLICATION FORM
Company/ Supplier Details
Company legal / Trading Name
Company/ CC Registration Number (where legally

required):
VAT Registration Number (if applicable):
Income Tax Reference Number (compulsory):
Web Address:
E-Mail Address (compulsory):
Telephone Number:
Toll-free Number:
Number of Full-time Employees:
Number of years in business:
Postal Address (Compulsory):
Code
Physical Address (Compulsory):
Code
Main Contact Person in your organisation for enquiries:

Name:
Position in organisation:
3
Cell Phone Number:
Telephone Number
E-Mail Address:
Alternative Contact Person in your organisation for enquiries:

There must be a second contact person unless the organisation only consists of one
person in which case you can record “NA”.
Name:
Position in organisation:
Cell Phone Number:
Telephone Number
E-Mail Address:
Company/ Supplier Classification: (Insert “Yes” in the relevant box/boxes)
ISO Importer Services Manufacturer Repairer Distributor Exporter Sales

Listed
Company/ Supplier Grouping Detail:

Type of Organisation:
(Insert “Yes” in the relevant box/ boxes below)

1.
Public Company (Ltd)
2.
Private Company (Pty) Ltd
3.
Close Corporation (cc)
4.
Foreign Company
5.
Section 21 Company
6.
Sole Proprietor
4
7.
Partnership
8.
Trust
9.
Government entity/ Parastatal
10.
Other (Specify)
Tax Compliance Status:
Insert Yes / No in the relevant box/ boxes below and provide the required Tax information
Note:
A valid SARS Tax Compliance System PIN/ PIN document and a printout demonstrating the
compliance status of the applicant must accompany the application and must be valid at the
date of closing of the application and at the time at which an applicant’s tax status is verified
by GEMS if no proof was supplied.
A printout from the eFiling system or a printout from the Central Supplier Database (CSD)
demonstrating the tax compliance status of the applicant which printout must have been
printed within 3 days prior to the closing date or submission date of the application.
Please find guidance steps on how to obtain a SARS printout demonstrating the compliance
status of the bidder:
i. Log in on SARS e-filling and capture your details.
ii. Click Tax Status
iii. Click Tax Compliance Status Verification
iv. Click New Verification Request
v. Insert company Tax reference number and security PIN as it appears on the PIN
document
vi. Insert security code as shown on the system then click continue
vii Do a screen print and attach this with your response.”
The option in the table below will be regarded as valid tax compliance. Where no valid tax
compliance exists for the applicant, proof from SARS needs to be provided for that party,
5
indicating that satisfactory arrangements have been made with SARS to meet the party’s tax
obligations.
A valid Tax Compliance System PIN/ PIN document

and the printout from the eFiling system or a printout
from the Central Supplier Database (CSD)
demonstrating the compliance status of the applicant Yes / No
not being submitted, may lead to GEMS requesting
such information as may be necessary to verify the
applicant’s tax status.
Tax Compliance System PIN / PIN document number:
Printout from the eFiling system or a printout from the
Central Supplier Database (CSD) demonstrating
compliance status of the applicant printed within 3 days
prior the closing date or submission date of the
application
Tax Reference Number:
Expiry Date of PIN:
Database Categories applying for
The work that the Scheme will perform in the 2023 financial year and onwards may
necessitate the provision of services in the undermentioned categories. Suppliers of the
following goods/ services are required to register on the database. The database is
categorised into two components.
Suppliers who, in the discretion of GEMS, have shown extensive experience and capability,
will be listed on the “Mature Supplier Component”1.
Suppliers who, in the discretion of GEMS, have not shown or do not have extensive
experience in a specific category may also be considered and listed in categories allocated
1
Extensive experience, good resources and facilities to execute the requirement, good previous performance on
assignments, supplier is at least a level 4 B-BBEE contributor.
6
for consideration as “developing suppliers”. This will be done under specific circumstances.
Start-up enterprises will also be listed on the “Developing Supplier Component”2.
Suppliers may be moved from the “Developing Supplier Component” to the “Mature Supplier
Component” once GEMS, in its discretion, confirms that they comply with the criteria set for
the “Mature Supplier Component”.
Where certification or accreditation is required, it will be required at quoting stage. However,

don’t apply if it is known that the service provider will not be able to be fully compliant at
quoting stage.
Please note that no more than two main groups can be registered for.
GEMS will not consider more than one supplier with the same or a majority of the
same owners/ directors for the same database sub-category. In such case, the
suppliers will be informed that only one of those suppliers can be considered for
placement on the database for that specific sub-category.
Please indicate the service/ services your organisation supply/ supplies and wish to register
for by indicating a “Yes” or marking it with an “X” or otherwise in the relevant box in the table
below for the category (“Mature” only or “Mature” or “Developing” that you deem relevant).
MAIN GROUP GOODS/ SERVICES MATURE MATURE OR

ONLY DEVELOPING
Mature Developing
CATERING Catering Services
Office Groceries
CONSULTING Accounting Services

SPECIALISTS
Actuaries
Auditing Services
2
Lack of extensive experience, but which would not negatively impact on the execution of the assignment,
provided the supplier is properly supported.
7
ONLY DEVELOPING
Mature Developing
Bid Evaluators - Auditing
Bid Evaluators - Marketing

and promotional services
Bid Evaluators - Medical

scheme core requirements
Bid Evaluators - Supply chain

management
Bid Evaluators - Other
Board Performance
Assessors
Compliance Auditors
Debt Collection Agencies
Dispute/ Complaint
Resolution Services
Forensic Investigators
Fraud Investigation Services

(Medical Schemes)
Health Economists
Healthcare Consultants
Integrated Reporting
Investment Advisors
Knowledge Management
Services
Legal Services
Library services
Statistical Analysis
8
ONLY DEVELOPING
Mature Developing
Trustee Trainers
(Governance, Finance,
Medical Scheme Industry)
Policy Developers
Procurement Database
Management Services
Procurement Execution
Services
Quality Assurance Services
Records Management
Services
Researchers/ epidemiologists
Risk Management Services
Specialist and other system,

software, data and business
intelligence tool developers
(inclusive of inter alia medical
schemes and contract
management)
Strategy Consulting
Strategic Sourcing Services
FACILITIES Access Control Systems

MANAGEMENT
Asphalt works (supply and
lay)
Building signage and

branding
Carpentry
9
ONLY DEVELOPING
Mature Developing
CCTV (Equipment and

Cameras)
Civil Engineering Work
Cleaning Services
Computer and Printer

Maintenance
Electrical Engineering Work-

Building
Fencing Services
Fire Prevention and

Protection Systems
Flower Arrangement
Furniture Repairs
General Building Construction
General maintenance
Glazing, curtain walls and

shop fronts
Handyman services
Hygiene Services
Health and Safety
Landscaping and horticulture

Services
Lifts
Locksmith
Mechanical Engineering
Works
10
ONLY DEVELOPING
Mature Developing
Offsite Storage
Pest Control Services
Photocopying, scanning,
framing, printing Services
Plumbing Services
Replacement of windows
Road marking and Signage
Security Services
Standby Generator
Structural Steelwork
Fabrication and Erection
Transcription Services
Upholstery Cleaning
Utility management
Waste management
Waterproofing of basements,
Roofs and Walls
HEALTHCARE CPD accredited training

MANAGEMENT services
Health and Wellness Provider
Medical devices and

appliances provision
On-site provider facility

assessment
Provider upskilling services
HR Employee Assistance
11
ONLY DEVELOPING
Mature Developing
Program Providers
Employee Relations Services
Employment Agencies
HR Consultants
Payroll outsourcing
Psychometrics
Response Handling
Services-Executive Coaching
Training and Development/

Skills Development
Vetting Services
ICT Infrastructure development
IT Consultants
IT Hardware Suppliers
IT Software Suppliers
ICT Training
System Developers
Software Development
MARKETING & Advertising, Marketing, Web

COMMUNICATION services and Digital media
Corporate Gifts/ Promotional

items
Events Management and

Exhibitions
Layout and Design of

Corporate Publications, and
12
ONLY DEVELOPING
Mature Developing
printing services
Media Monitoring
Media sales services/agents
Mobile and electronic

communication services
Photography and audio

visuals
Public Relations
Stakeholder Management
MOTOR VEHICLE Certificate of Roadworthiness

RELATED (CoR)/ Certificate of Fitness
(Cof) testing
Licensing
Repairs
Tyres
OFFICE Carpet/Tiles Supplies

SUPPLIES
Fuel/Diesel Supplies
Health and Safety Equipment/

Signage/ Consumables
Suppliers
Office Furniture Suppliers
Office Plants Suppliers
Stationery
PROFESSIONAL Architectural Services
13
ONLY DEVELOPING
Mature Developing
CONSULTATIONS B-BBEE Advisory services
and implementation partners
Civil/Structural engineers
Electrical engineers
Geotechnical and
Environmental Consultants
Health and Safety

Consultants
Interior designers
Mechanical Engineers
Property Values
Quantity Surveyors
SMME Business development

support (mentors & advisors)
Space Planners
TRAVEL AND Courier services

LOGISTICS
Messenger/ Delivery Services
(Documents & People)
Travel Agents
OTHER
SERVICES
Track Record in commodity categories applied for
List preferably all, but at least the four (4) largest, most important relevant contracts/
assignments completed by your organization, with a focus on those in the last five years.
These contracts/ assignments must be relevant to the categories you are applying for.
14
Should you not be able to list at least four (4) contracts/ assignments, please indicate your
level of experience and the industry in which you have the experience. GEMS complies with
the POPI Act and requires client information for the purpose of determining the extent of the
experience in the commodity categories applied for. Should a client prohibit the use of its
name in demonstrating an applicant’s experience, the application must inform GEMS there is
a constraint in providing the full detail. The applicant must still indicate the description of the
service rendered, the budget range in which this project falls (for example between R5
million and R6 million) and the industry in which the client falls without providing the client
name.
If experience is vested in an individual, indicate the experience vested in the individual, but
clearly identify the individual. If the space below is not sufficient, you may insert additional
rows in the table below.
Description of Work Size of Name of Client Contract period Reference

Performed so it is contract (from when till letter
clear what the (Rand value) when) provided?
scope of work was Yes/No
Financial Soundness
Provide, as an attachment, the confirmation of your financial soundness to prove that you
are a going concern. This could be done through one of the following options: (Indicate by
marking (“X”) in the table below to confirm the option that will be submitted).
# Option Choice
1. Audited financial statements signed by the relevant parties
2. Proven financial statistics covering at least assets and liabilities through
15
documentary evidence acceptable in the financial and accounting
environment
3. A letter signed by the CEO/ CFO indicating the financial statistics
covering at least assets and liabilities with a comment on the going
concern status of the organisation
The information provided must cover the last full financial year, preceding the submission
date of this application and it must confirm in writing, or it must prove that the relevant party
is a going concern. An example of such full financial year is noted herewith: The application
is submitted on 1 June 2023, and the financial year end of the applicant is 30 April 2023.
The “last full financial year” for this applicant will thus be 1 May 2021 to 30 April 2022 as the
30 April 2023 financial year-end information may not yet be available.
Resources in commodity categories applied for
List the key resources (individuals/ team members) you have available to address
requirements and who are relevant to the categories you are applying for. If the space
below is not sufficient, you may insert additional rows in the table below. Please also attach
a summary paragraph as an addendum to this document for each of the key resources
detailing their expertise by referencing types of assignments and skills.
Names of key resources Years of relevant Qualifications

experience
Facilities/ infrastructure in commodity categories applied for
16
List your available facilities to address requirements and which are relevant to the
categories you are applying for.
Examples of infrastructure:
 Where you intend to provide courier services you would want to demonstrate your
vehicle(s) that you use.
 Where you intend to do photography, you need to have a camera you can use.
 Tools available to provide the service, i.e. laptops, computer software, etc.
If the below space is not sufficient, you may duplicate this table and attach it to this
application form.
Description of relevant facilities/ infrastructure
SMME Status of your Enterprise:
Applicants who regard themselves as an SMME as defined by the National Small Enterprise
Act, 1996 (Act No 102 of 1996) as amended by the National Small Business Amendment Act
(Act 26 of 2003) and the National Small Business Amendment Act (Act 29 of 2004) must
complete this portion.
Do you regard yourself as a SMME in terms of the Act? (Indicate Yes/

No)
If yes, please indicate with an “X” in the relevant box in each column numbered A; B; or C
17
Sector or sub-sector
Total full time Total annual
in accordance with
equivalent of turnover
the Standard
A Size or class paid B C
Industrial
employees
Classification in Less than:
Less than:
which you operate
Medium 51-250 ≤ R35,0 million
Agriculture
Small 11-50 ≤ R 17,0 million
Micro 0-10 ≤ R 7,0 million
Mining and Medium 51-250 ≤ R 210,0 million

quarrying Small 11-50 ≤ R 50,0 million
Manufacturing Medium 51-250 ≤ R 170,0 million

Electricity, gas and Medium 51-250 ≤ R180,0 million

water Small 11-50 ≤ R 60,0 million
Construction Medium 51-250 ≤ R 170,0 million

Retail and motor Medium 51-250 ≤ R 80,0 million

trade and repair Small 11-50 ≤ R 25,0 million
service Micro 0-10 ≤ R 7,5 million
Wholesale trade Medium 51-250 ≤ R 220,0 million

18
Sector or sub-sector Total full time Total annual
in accordance with equivalent of
A Size or class B turnover C
the Standard paid
Industrial employees Less than:
Classification in
Catering, Medium 51-250 ≤ R 40,0 million

accommodation and Small 11-50 ≤ R 15,0 million
other trade Micro 0-10 ≤ R 5,0 million
Transport, storage Medium 51-250 ≤ R 140,0 million

and communications Small 11-50 ≤ R 45,0 million
Finance and Medium 51-250 ≤ R 85,0 million

business services Small 11-50 ≤ R 35,0 million
Community, social Medium 51-250 ≤ R 70,0 million

and personal Small 11-50 ≤ R 22,0 million
services Micro 0-10 ≤ R 5,0 million
Indicate your ultimate classification in the table below. The “Total annual turnover,” as
indicated in the table above, shall be the determining factor of the ultimate classification.
SMME Classification Indicate “Yes” against the correct classification
Micro
Small
Medium
List all Partners, Proprietors and Shareholders (Compulsory):

Name Position in Occupation ID Number
Company
19
Name Position in Occupation ID Number
Company
Note: Where owners are themselves a Company or Partnership, the individual owners of
such holding firm must be identified and an attachment may be provided if necessary.
If you are registered with CIPC/ CIPRO, the relevant documents indicating directorship, must
be attached as an addendum to this application form.
Equity Ownership
Indicate the percentage of equity ownership for your company in the table below. Should
you be owned by a holding company, indicate the percentage ownership by your parent
company. Equity ownership should add up to 100%. This section is compulsory.
Percentage owned by the following groups

Ethnicity Male % Female % Disabled %
African
Coloured
Indian
White
B-BBEE Status in terms of the Codes of Good Practice
20
In terms of the B-BBEE Act and the Codes of Good Practice issued by the DTIC, as
amended, an applicant must provide proof of its level contributor status. The proof
submitted must be valid at the closing date of the submission.
Proof may be in any of the forms noted hereunder. GEMS will accept any legally acceptable
proof.
1. A B-BBEE certificate issued by a SANAS accredited B-BBEE verification agency.

The B-BBEE certificate must be accompanied by the page containing the detailed
score obtained for each element of the scorecard if not contained in the main body of
the certificate.
2. A sworn affidavit signed on the same date by the designated owner and
Commissioner of Oaths, proving the status of the measured entity to be an EME or a
QSE (only where the QSE has at least 51% Black ownership) or
3. A CIPC certificate where relevant or
4. A certificate from the DTIC, indicating EME or QSE status.
NB: The proof submitted must be valid at the closing date of the submission. Only proof
aligned with the recently amended Codes of Good Practice will be considered.
Start-up enterprises must be measured as Exempted Micro-Enterprises in terms of the

Codes of Good Practice for the first year following their formation or incorporation. This
provision applies regardless of the expected total revenue of the start-up enterprise. In order
to qualify, the enterprise must provide an independent confirmation of its status.
Please indicate your B-BBEE status as follows and provide the proof in substantiation
thereof:
Classification Indicate Indicate Indicate the Proof submitted

“Yes” your level expiry date of (Compulsory)
against your contributor the B-BBEE (Indicate Yes/ No)
classification status document Certificate Affidavit
Exempted Micro
21
Classification Indicate Indicate Indicate the Proof submitted
“Yes” your level expiry date of (Compulsory)
against your contributor the B-BBEE (Indicate Yes/ No)
classification status document Certificate Affidavit
Enterprise
(Any enterprise with an
annual total revenue of
R10 million or less)
Start-up enterprise
(A recently formed or
incorporated entity that
has been in operation
for less than 1 year. A
start-up enterprise does
not include any newly
constituted enterprise
which merely is a
continuation of a pre-
existing enterprise)
Qualifying small
enterprise
annual total revenue of
between R10 million
and R50 million)
Generic
annual total revenue
above R50 million)
No information
available
Indicate score allocated to the relevant elements, where applicable:
22
# Element Target Score
1. Ownership
2. Management control
3. Skills Development
Enterprise and Supplier Preferential Procurement

Development
4. Supplier Development
Enterprise Development
5. Socio-economic Development
Indicate your % Black ownership %
Indicate your % Black women ownership %
Are you a B-BBEE controlled company? (Indicate Yes/ No)

(Means a juristic person having shareholding or similar members’
interest, in which Black participants enjoy a right to Exercisable Voting
Rights that is at least 51% of the total such rights measured using the
Flow Through Principle)
Are you a B-BBEE owned company? (Indicate Yes/ No)

(Means a juristic person having shareholding or similar members’
interest, that is B-BBEE controlled, in which Black participants enjoy a
right to economic interest that is at least 51% of the total such rights
measured using the Flow Through Principle)
Are you an Empowering Supplier? (Indicate Yes/ No)

(A compliant entity, comply with all regulatory requirements of the
country and should meet at least three if it is a large enterprise or one
if it is a QSE of the following criteria:
a) At least 25% of cost of sales excluding labour cost and
depreciation must be procured from local producers or local
23
supplier in SA, for service industry labour cost are included
but capped to 15%.
b) Job creation – 50% of jobs created are for Black people
provided that the number of Black employees since the
immediate prior verified B-BBEE Measurement is maintained.
c) At least 25% transformation of raw material/beneficiation,
which include local manufacturing, production and/or
assembly, and/or packaging.
d) Skills transfer - at least spend 12 days per annum of
productivity deployed in assisting Black EMEs and QSEs
beneficiaries to increase their operation or financial capacity)
Are you a Black Designated Group owned Company?

Indicate (Yes/No)
If yes:
Indicate the percentage (%) of ownership in the relevant fields below (compulsory)
Percentage (%)
Black people who are youth as defined in the National Youth

Commission Act of 1996;
Black people who are persons with disabilities as defined in the

Code of Good Practice on employment of people with disabilities
issued under the Employment Equity Act;
Unemployed Black people not attending and not required by law

to attend an educational institution and not awaiting admission to
an
educational institution;
Black people living in rural and under developed areas
Black military veterans who qualifies to be called military veteran

in terms of the Military Veterans Act 2011
24
Signature...........................................................................................................
(Must be signed in the presence of a Justice of the Peace, Magistrate or Commissioner of
Oaths).
The date of signature by both parties (Commissioner and Signatory) must be the same.
Date...................................................................................................................
Place..........................................................................….............................…….
Signed: Justice of the Peace/Magistrate/Commissioner of

Oaths*…………………………………………………………………………......
Full first names and surname: ………………………………………………….
Designation / Rank ………………………………………………………….......
Date...............................................................................................................
Place.........................................................…...........…...................................
STAMP:
25

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CLOSING DATE FOR APPLICATION

08 DECEMBER 2023 @ 11h00

Version October 2023

Annexure “A” - Declaration of Interest Form

B-BBEE Broad-Based Black Economic Empowerment

Company/ Supplier Details

Company legal / Trading Name

Company/ CC Registration Number (where legally

VAT Registration Number (if applicable):

Income Tax Reference Number (compulsory):

E-Mail Address (compulsory):

Number of Full-time Employees:

Number of years in business:

Postal Address (Compulsory):

Physical Address (Compulsory):

Main Contact Person in your organisation for enquiries:

Alternative Contact Person in your organisation for enquiries:

Company/ Supplier Classification: (Insert “Yes” in the relevant box/boxes)

ISO Importer Services Manufacturer Repairer Distributor Exporter Sales

Company/ Supplier Grouping Detail:

(Insert “Yes” in the relevant box/ boxes below)

Tax Compliance Status:

A valid Tax Compliance System PIN/ PIN document

Expiry Date of PIN:

Database Categories applying for

Where certification or accreditation is required, it will be required at quoting stage. However,

MAIN GROUP GOODS/ SERVICES MATURE MATURE OR

CONSULTING Accounting Services

Bid Evaluators - Auditing

Bid Evaluators - Marketing

Bid Evaluators - Medical

Bid Evaluators - Supply chain

Bid Evaluators - Other

Debt Collection Agencies

Fraud Investigation Services

Quality Assurance Services

Risk Management Services

Specialist and other system,

Strategic Sourcing Services

FACILITIES Access Control Systems

Building signage and

CCTV (Equipment and

Civil Engineering Work

Computer and Printer

Electrical Engineering Work-

Fire Prevention and

General Building Construction

Glazing, curtain walls and

Health and Safety

Landscaping and horticulture

Pest Control Services

Road marking and Signage

HEALTHCARE CPD accredited training

Health and Wellness Provider

Medical devices and

On-site provider facility

Provider upskilling services

Employee Relations Services

Training and Development/

ICT Infrastructure development

MARKETING & Advertising, Marketing, Web

Corporate Gifts/ Promotional

Events Management and

Layout and Design of