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SUPPLIERPre-Qualification QuestionnaireProject 1: Cooke 1 101 Level East water door projectProject 2: Cooke 1 Underground 101 South Side cross cutProject - (Vent hole 101 to 106 level and 3 x 80m plugs)Note: Detailed scope of work will be attached on the Coupa system afterthe Site meeting.
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRECooke 1 OperationsAPPLICANT (COMPANY) NAME:INDICATE FROM WHICH COMMUNITY:DATE:2Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIREREFERENCE NUMBER:Gold Division – Cooke 1 DivisionOnsite services of underground cross cutting, ventilation hole area cleaning,installation & building of plugs and pipes, Waterdoor cleaning. (Detailed scopeof work to be attached on Coupa system after Site meeting) Interested YES / NONEW VENDOREXISTING VENDORVENDOR NUMBERCOMPANY E-MAIL ADDRESS:COMPANY E-MAIL ADDRESS:3Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIREALL QUESTIONS TO BE ANSWERED IN DETAIL (PLEASE PRINT OR TYPE)ENSURE THAT THE EACH PAGE OF QUESTIONNAIRE IS SIGNEDSECTION 1: GENERAL1. COMPANY / CC DETAILS1.11.21.31.41.51.61.7Full name(s) of Company or Closed Corporation:Trading as:Previous Name(s) (if applicable):Date registered at Registrar of Companies:Company/CC:CompanyClosed CorporationPhysical Address:Where do you operate from?Registered Business PremisesIndustrial PremisesPrivate ResidenceFarm or small/holding (Plot)YesNoYesNoYesNoYesNo1.8Postal Address:Code:1.9Telephone Number:4Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRE1.101.11Fax Number:E-mail Address:2. COMPANY / CC PROFILEAttach Details of the following:2.1 Brief Summary of Company/CC History/ ExperienceAttachedNot Attached2.2 Do you currently work as an employee for Sibanye-Stillwater?YesNo2.3 Were you previously employed by Sibanye-Stillwater orAnglo American Platinum? If yes, provide more information.YesNo(Dates, Position, Location and Reason for leaving)2.4 Have you ever provided a service or product to Sibanye-Stillwater?2.5 Attach a valid B-BBEE certificate.YesNoYesNo2.6 How does your company connect to the Internet?Does not connectModemISDNADSLOtherIf other, please specifyATTACH ALL INFORMATION / ATTACHMENTS APPLICABLE TO SECTION 1 HERE5ConfidentialN/A
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRESECTION 2: TECHNICAL QUESTIONNAIRE2.1 Technical Questions2.1.1 Provide reference where your company previous done underground cross cutting,ventilation hole area cleaning, installation & building of plugs and pipes,Waterdoor cleaning. (Detailed scope of work to be attached on Coupa system after Sitemeeting)DescriptionDateCompletedTotal Valueof workName of ClientContact nr123452.1.2 Will you as the main contractor perform the work or will the work be performed by asub-contractor?2.1.4 Will you have a site supervisor on site at all times while work is conducted?2.2Are your premises available for inspection?YesNoIf no, please supply reason2.3Risk Assessment Policy (Mandatory on Safety Critical/Hazardous Items)YesNoN/A6Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRE2.3.1 Do you have a risk assessment policy?Attach an example of the proposed risk assessment documentAttachedNot attachedN/A2.5 Tools and Equipment2.5.1 What tools/ equipment do you propose to utilise for this contract?2.6 How will you transport your teams between sites and where will your base office be?2.7 Has your Company ever been investigated or your contract cancelled by any othercompany due to technical reasons?YesNoIf yes, please state the following2.7.1 Name of Company who investigated or rejected you:2.7.2 Service that was investigated?2.7.3 What was done to rectify the problem?7Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRE2.8 Dealings with the Mining Industry2.10.1 Do you have dealings with other Mining Houses or Mines?If yes, please specify the type of services, duration and with which Mining HousesOff ContractOn Contract2.11 How many people are currently employed by your company?ATTACH ALL INFORMATION / ATTACHMENTS APPLICABLE TO SECTION 2 HERE8Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRESECTION 3: FINANCIAL QUESTIONNAIRE3.1 Tax number of Company and Subsidiaries3.2 Bank and Bank Number of Companies(Attach a list if space is not adequate)AttachedNot Attached3.3 If any auditing company is used, supply company’s name, address and telephonenumber3.4 Important: Mandatory Attachments3.4.1 Attach a RECENTLY CERTIFIED copy (please ensureALL PAGES are certified) of your CC or CompanyRegistration Certificate, CC or Company and/orOwner name-change.3.4.2 Attach a copy of your company letterheadAttachedAttachedNot AttachedNot Attached3.4.3 Attach an ORIGINAL CANCELLEDCompany Cheque or bank statement (bank date stamp required)9Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRE3.5 Has your company ever investigated or rejected by any other company due to financialreasons?YesNoIf Yes, Please State the Following:3.5.1Name of Company who investigated or rejected to:3.5.2Details of irregularities concerned:3.5.3 What was done to rectify the problem?ATTACH ALL INFORMATION / ATTACHMENTS APPLICABLE TO SECTION 3 HERE10Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRESECTION 4: SECURITY QUESTIONNAIRE4.1 Full names, Telephone Numbers, ID Numbers and Cell Phone Numbers of all Directors,Partners, Members or Owners of the Company or Closed Corporation4.2 Attach a Legible Copy of the ID Documents of AllDirectors, Partners, Members or Owners of the Companyor Closed CorporationAttachedNot Attached4.3 List the Names of all Businesses in which the above Directors, Partners, Owners orMembers have been involved in.11Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRE4.4 Full Names, ID Numbers, Home Addresses and Telephone Numbers of all Manager(s)And Sales Representatives employed by the Company/CC and Subsidiaries4.5 Name all Relatives Employed by Sibanye-Stillwater4.6 Name all Persons Employed at Sibanye-Stillwater who may benefit from your dealingswith the Mine12Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRE4.7 State if any of your Employees, including Hired Labour, have ever been convicted ofany Criminal Offence. If so, when, where and what was the offence?4.8 Has the Company / Closed Corporation or Any Subsidiariesor Agent been investigated by any of the Mining HousesYesNoor Mines?4.9 Was your Company investigated or rejected by any otherCompany because of Security Reasons?YesNoIf yes, please supply full details?ATTACH ALL INFORMATION / ATTACHMENTS APPLICABLE TO SECTION 4 HERE13Confidential
SIBANYE-STILLWATER SUPPLIER QUESTIONNAIRESECTION 5: IMPORTANT NOTIFICATIONSEnsure that all information provided on this form is true and correct.Any inaccurate, false or misleading information provided in this questionnaire, could leadto disqualification and possible investigations.We the undersigned, duly authorised by our company, the necessary action may be takenagainst the Company concerned and we may choose not to do business and/or cease to dobusiness with such a Company.TO BE COMPLETED AND SIGNED BY AN AUTHORISED COMPANY REPRESENTATIVENAME (PRINT)SignedDesignationDatePLEASE NOTE: UNSIGNED OR INCOMPLETE QUESTIONNAIRES WILL BE REJECTEDFor Queries contact:E-mail:Rudzani nfidential
SUPPLIER Pre-Qualification Questionnaire Project 1: Cooke 1 101 Level East water door project Project 2: Cooke 1 Underground 101 South Side cross cut Project - (Vent hole 101 to 106 level and 3 x 80m plugs) Note: Detailed scope of work will be attached on the Coupa system after the Site meeting.
