1

SUPPLIER APPLICATION FORM 2017/2018

Return to: Namibia Qualifications Authority Corner of Bismarck & Dr. W Kultz Street Windhoek

2

To be completed by all vendors seeking registration as an approved

supplier/service provider of goods, works and services to Namibia Qualifications

Authority

The application form must be completed in full and be signed. All Fields on the

application must be completed by the applicant.

A company profile should accompany the registration form, but will not substitute

accepted as a substitute for the application form- all fields on application must be

completed by the applicant

Applicants may be contacted via email and must therefore submit operating email

addresses.

It should be noted that the Namibia Qualifications Authority reserves the right to

accept or reject any application on reasonable ground.

NOTE WELL: The following should accompany the Application 1. Certified copy

of company registration document 2. Tax Good Standing certificate 3.

Company Profile 4. A valid Affirmative Action Compliance Certificate , proof

from Employment Equity Commissioner that a bidder is not a relevant

employer, or exemption issued in terms of section 42 of the Affirmative

Action Act, 2008. 5. A certificate indicating SME status(for Bids reserved for

SMEs)

Applicant must comply with all the registration criteria for registration to be

finalized, failure to do so may result in the application being declined

1. Supplier Details

Company Registration number

Income Tax number

Email address

Telephone Number

Fax Number

Number of fulltime employees

2. Postal Address Physical Address

3

3. Company/Supplier classification (mark with x)

Services Goods

Region

Town

4. Please tick the relevant box and supply copy

Tax Good standing certificate Attached

Expiry date

VAT Registration No:

5. Type of Firm Please tick the relevant Box and supply a certified copy of

registration document

1 Private Company (PTY) LTD

2 Close Corporation (CC)

3 Public Company LTD

4 Partnership

5 Other (specify)

6. Main Contact for the company

Name

Resignation

Telephone Number

Cellphone Number

Fax Number

Email Address

4

7. Enterprise Status (mark with x)

SME

Large

8. List all directors/members/partners/shareholders

Name Position Held ID Number/Passport/Registration number

9. Trade Experience

Name Three trade references

Business Name Contact number Contact person Value of business in N$

10. Financial Information

Indicate Annual turnover excluding VAT during the past three years

Year Annual Turnover N$

5

11. Declaration of any conflict of interest

I/We the undersigned acknowledge(s) that :

The information furnished is true and correct

Any conflict of interest will be declared in the comment space below

Have you been providing services /products to Namibia Qualifications Authority for the

past 12 months?

If yes, furnish particulars

______________________________________________________________________

______________________________________________________________________

12. Are you or any person connected with the bidder applicant presently employed by

the NQA?

Yes NO

NO Yes

6

13. Do you presently, or will you potentially have any conflict of interest in connection

with a supply contract with the NQA? (A conflict of interest may arise in particular

as a result of economic interests, affinities of various forms, family or emotional

ties, or any other relevant connection or shared interest)

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

_______________ _______________________

Full Name Capacity

_______________ _______________________

SIGNATURE DATE

7

LIST OF GOODS AND SERVICES

Suppliers may choose maximum 4 commodities (mark with x )

1. Goods

Supply of:

Furniture & Fittings

Computer Equipment (Desktops, Monitors, Laptops etc)

Office equipment (Photocopy, Projectors, Cameras, Audio & Video systems, Microwaves, Electrical Kettle, Fridge etc.)

Air conditioners

Motor vehicles Including Trailers

Corporate Clothing (Uniform)

Flowers

Awards / Framing of certificates

Promotional Items

Corporate Gifts

Blinds & Awnings

Carpets

Crockery, Cutlery, glasses, Table Cloths & other related utensils

Groceries / refreshments

Cleaning Materials

Protective clothing

Shelving (Steel and Wood)

First Aid Kit & Equipment

Newspapers, Periodicals, Journal, Publications and other Media

Sportswear and related Sport Supplies

Locks & Keys

Intercom systems

Safes

Remote Control, Roller Shutter doors, Turnstiles and booms

Cartridges

Telephonic equipment including headsets etc

.

2. Works

Repair & Maintenance of Office Equipment

Construction & renovation

Plumbing

Civil work

Civil Engineering

8

Air-conditioning specialist

Electrical Maintenance

Fire Extinguisher Services

Painting

3. Consultancy Services

Management Consultancy

Performance management Consultancy

Personal Development Consultant

Remuneration and salary structuring Consultancy

Skills Analysis and Development Consultancy

Staff wellness services ( HIV/AIDS, Cancer & Team building)

Transcription Services

Voluntary Counseling testing

Training & Development Consultants

Recruitment Agencies

Industrial Relation Services

IT Professional Services

Architectural Services

Quantity surveyor services

Interior design Services

Audit services (External)

Quality Assurance Consultancy (SMEs)

Procurement advisory Services

Legal (Advisory ) Services

Surveillance Services

4. Non- Consultancy services

Accommodation in Various Towns in Namibia

Accommodations International

Air ticket and transportation services

Advertising services

Branding & Marketing services

Layout & designing

Electronic Media

9

Outdoor/ Billboard media

Printed Media (Flyers, Brochures)

Printing Services

Licensing & Computer software

Dry Cleaning Services

Courier Services

Cleaning Services

Security Services

Insurance Services

Telephone services

Internet Connection services

Catering Services

Conference Facilities / Venues

Carpet/ Upholstery Cleaning

Air-conditioning services

Archiving & Related Services

IT Hardware, Network, Maintenance and Support

Removal Services (Furniture etc)

Renovations (Dry walls/partitioning, ceiling, flooring, Painting)

CCTV system services (Network cameras, DVR, Backup)

Fraud detection Services

Investigations

Short training Courses & Workshops

ICT Training

Procurement Training

Quality Assurance Training

Human Resources Training

Corporate Training

Car Hiring Services

Stitching and Binding Services