Application Form Only applications of companies who have responded to the RFI and submitted the required documentation will be considered. If you have not yet responded to the RFI – please click here. Application Form - 2022 KHUMO PROGRAMME APPLICATION FORM Thank you submitting your interest in applying for the Khumo Enterprise Development Programme.The Khumo Programme is an intensive Enterprise Development Programme sponsored by Khumani Mine to develop selected SMME’s. Kindly note that only qualifying companies who participated in the RFI process and submitted all the required documentation will be considered for the Khumo Programme.Kindly ensure that you complete the whole application form (Page 1 – Page 14) in order to apply for the programme. After the application process a formal selection process will be followed. Please note that the completion of this form does not automatically include your company in the programme. All applications must be submitted by no later than 13:00 on Friday 28 January 2022. (Extended Deadline)PLEASE NOTE THAT NO LATE SUBMISSIONS WILL BE CONSIDERED.SECTION A:Please select which answer is correct - please select YES or NO : 1. Is the business a small, medium or micro enterprise? (Annual turnover of less than R50 million and classified as an EME or QSE as per the B-BBEE Codes of Good Practise.) YESNO 2.) Is the business minimum 51% black owned?YESNO 3. Does the business have 51% or more female ownership? YESNO 4.) Are any of the business owners a disqualified or delinquent director?YESNO 5.) Are the business owners able to trade and operate without limitation within the Republic of South Africa?YESNO 6.) If you answered No above in question 5 above, please give the name(s) of the director(s) who cannot trade / operate without limitation in the Republic of South Africa and the reason(s): 7.) Are the business owner(s) operating more than one business?YESNO 8.) If you answered Yes in question 7 above, please give a brief description of other businesses / business activities: 9.) Are the business owners full time involved in the business?YESNO 10.) If you answered No in question 9 above, please indicate whether the business owners are willing to be full time involved if the business is selected for the Enterprise Development Programme? 11. For how long has the business been operational: 12. Where is the business situated (Town and Municipality): 13. Is the business currently part of an enterprise development / supplier development / incubation programme? YESNO 14. If you answered Yes above, please give a brief description, as well as a description of previous programmes completed: 15. Is the business currently registered as a supplier on the Assmang – Khumani Iron Ore database? YESNO 16. Please provide a list of businesses (If applicable) to whom the business is currently supplying goods or services, and please specify which goods or services are being supplied: 17. If selected for the Enterprise Development Programme, are you willing to sign a Khumani Enterprise Development Beneficiary Agreement? YESNO 18. Has the company or any of the directors ever been placed under administration? YESNO 19. If you answered yes in question 18 above, please give the name(s) of the director(s) who was placed under administration and a brief description: 20. Please select the applicable description: The business has a good / average / bad credit record. GoodAverageBad 20a. Give description of rating you selected in 20 above 21. Are you willing to give consent to a credit check? YESNO 22. Does any of the business owners have a criminal record?YESNO If you answered Yes in question 22 above, please give a brief description - stating the following per person. a. Name of Owner Who Was Convicted of Offense b. Year When Offense Was Committed and Description of Offense c. Description of Sentence 23. Are you willing to give consent for a criminal record check?YESNO 24. Are you, a family member, or any other related person employed by Assmang (Pty) Ltd – Khumani Iron Ore? YESNOIf you answered YES to to question 24 above, please provide detail. 24a. Name and Surname 24b. Position 24c. Department: 24d. Contact Details:This is the end of section A. Please continue to section B below.SECTION B: REGISTERED COMPANY NAME TRADING NAME REGISTRATION NUMBER CONTACT NUMBER BUSINESS ADDRESS Street Address City Province Postal Code POSTAL ADDRESS POSTAL ADDRESS City Province Postal Code EMAIL PLEASE GIVE A BRIEF DECRPTION OF THE COMPANY PLEASE LIST THE CORE PRODUCTS / SERVICES THE BUSINESS PROVIDESOWNERSHIP DETAILList owners belowOWNER 1 DETAIL Owner 1 NAME SURNAME Owner 1 ID NUMBER OWNER 1 GENDERMALEFEMALE Owner 1 POSITION Owner 1 % SHARE Owner 1 % TIME DEVOTED TO BUSINESSOWNER 2 DETAIL Owner 2 NAME SURNAME Owner 2 ID NUMBER OWNER 2 GENDERMALEFEMALE Owner 2 POSITION Owner 2 % SHARE Owner 2 % TIME DEVOTED TO BUSINESSOWNER 3 DETAIL Owner 3 NAME SURNAME Owner 3 ID NUMBER OWNER 3 GENDERMALEFEMALE Owner 3 POSITION Owner 3 % SHARE Owner 3 % TIME DEVOTED TO BUSINESSOWNER 4 DETAIL Owner 4 NAME SURNAME Owner 4 ID NUMBER OWNER 4 GENDERMALEFEMALE Owner 4 POSITION Owner 4 % SHARE Owner 4 % TIME DEVOTED TO BUSINESSOWNER 5 DETAIL Owner 5 NAME SURNAME Owner 5 ID NUMBER OWNER 5 GENDERMALEFEMALE Owner 5 POSITION Owner 5 % SHARE Owner 5 % TIME DEVOTED TO BUSINESSCONTACT PERSON DETAILS CONTACT PERSON NAME AND SURNAME CONTACT PERSON NUMBER CONTACT PERSON EMAIL CONTACT PERSON RESIDENTIAL ADDRESS Street Address City Province Postal Code CONTACT PERSON POSTAL ADDRESS Street Address City Province Postal CodeCOMPANY REGISTRATION AND COMPLIANCE DETAILS (PLEASE INDICATE WITH N/A WHERE NOT APPLICABLE) COMPANY REGISTRATION NUMBER INCOME TAX NUMBER UIF VAT LETTER OF GOOD STANDING NUMBER SKILLS DEVELOPMENT LEVY NUMBER CIBD / PSIRA NUMBER BANK ACCOUNT DETAILS DOES YOUR COMPANY HAVE A HEALTH AND SAFETY FILE?YESNO IS THE COMPANY IN GOOD STANDING WITH SARS?YESNO DOES THE COMPANY HAVE A MINING HEALTH AND SAFETY MANAGEMENT FILE?YESNOBUSINESS INSURANCE IS THE BUSINESS INSUREDYESNO PLEASE PROVIDE BRIEF DESCRIPTION IF INSURED (INCLUDING PROFESSIONAL INDEMNITY, PUBLIC LIABILITY COVER, AMOUNT COVERED)TURNOVER WHEN IS THE FINANCIAL YEAR END OF THE BUSINESS? ANNUAL TURNOVER FOR 2019 ANNUAL TURNOVER FOR 2020 ANNUAL TURNOVER FOR 2021HUMAN RESOURCES DOES YOUR BUSINESS HAVE A CODE OF CONDUCT?YESNO DOES THE BUSINESS HAVE SIGNED EMPLOYEE AGREEMENTS WITH THE STAFF?YESNO HOW MANY STAFF IS EMPLOYED FULL TIME? HOW MANY STAFF IS EMPLOYED PART TIME?OPERATIONAL READINESS DOES YOUR COMPANY HAVE IT'S OWN BUSINESS PREMISES?YESNO DOES YOUR COMPANY HAVE IT INFRASTRUCTURE?YESNO BRIEFLY DESCRIBE THE ASSETS (VEHICLES, EQUIPMENT AND INFRASTRUCTURE) OF THE BUSINESS PLEASE RATE THE POTENTIAL OF THE BUSINESS TO EXPANDWorst12345Best PLEASE MOTIVATE YOUR ANSWER ABOVE WHAT DOES YOUR BUSINESS REQUIRE TO EXPAND? WHAT ARE THE GREATEST CHALLENGES THE BUSINESS IS FACING?MANAGEMENT AND KEY STAFF MEMBERSMANAGER 1 DETAIL MANAGER 1 NAME AND SURNAME MANAGER 1 POSITION MANAGER 1 QUALIFICATIONS MANAGER 1 EXPERIENCEMANAGER 2 DETAIL MANAGER 2 NAME AND SURNAME MANAGER 2 POSITION MANAGER 2 QUALIFICATIONS MANAGER 2 EXPERIENCEMANAGER 3 DETAIL MANAGER 3 NAME AND SURNAME MANAGER 3 POSITION MANAGER 3 QUALIFICATIONS MANAGER 3 EXPERIENCEMANAGER 4 DETAIL MANAGER 4 NAME AND SURNAME MANAGER 4 QUALIFICATIONS MANAGER 4 EXPERIENCE MANAGER 4 POSITIONMANAGER 5 DETAIL MANAGER 5 NAME AND SURNAME MANAGER 5 QUALIFICATIONS MANAGER 5 EXPERIENCE MANAGER 5 POSITIONTRACK RECORD (Please provide a list of current or previous contracts/projects completedTRACK RECORD CUSTOMER 1 CUSTOMER 1 NAME CUSTOMER 1 PROJECT DESCRIPTION CUSTOMER 1 PROJECT START AND COMPLETION DATES CUSTOMER 1 - WAS CONTRACT COMPLETED ON TIME? IF NOT, GIVE REASONS CUSTOMER 1 ESTIMATED PROJECT VALUETRACK RECORD CUSTOMER 2 CUSTOMER 2 NAME CUSTOMER 2 PROJECT DESCRIPTION CUSTOMER 2 PROJECT START AND COMPLETION DATES CUSTOMER 2 - WAS CONTRACT COMPLETED ON TIME? IF NOT, GIVE REASONS CUSTOMER 2 ESTIMATED PROJECT VALUETRACK RECORD CUSTOMER 3 CUSTOMER 3 NAME CUSTOMER 3 PROJECT DESCRIPTION CUSTOMER 3 PROJECT START AND COMPLETION DATES CUSTOMER 3 - WAS CONTRACT COMPLETED ON TIME? IF NOT, GIVE REASONS CUSTOMER 3 ESTIMATED PROJECT VALUETRACK RECORD CUSTOMER 4 CUSTOMER 4 NAME CUSTOMER 4 PROJECT DESCRIPTION CUSTOMER 4 PROJECT START AND COMPLETION DATES CUSTOMER 4 - WAS CONTRACT COMPLETED ON TIME? IF NOT, GIVE REASONS CUSTOMER 4 ESTIMATED PROJECT VALUETRACK RECORD CUSTOMER 5 CUSTOMER 5 NAME CUSTOMER 5 PROJECT DESCRIPTION CUSTOMER 5 PROJECT START AND COMPLETION DATES CUSTOMER 5 - WAS CONTRACT COMPLETED ON TIME? IF NOT, GIVE REASONS CUSTOMER 5 ESTIMATED PROJECT VALUEMOTIVATION Please explain why you think the business should be part of the Khumani Enterprise Development Programme. (Maximum of 200 words.) DECLARATIONYour application form mustbe signed by an authorised representative of the business.I hereby duly declare that: 1. I am authorised to sign this declaration on behalf of : 2 . The information provided is true and correct to the best of my knowledge3. I hereby give consent to Phil 4 Consulting (Pty) Ltd and Assmang (Pty) Ltd – Khumani Iron Ore to access, use, process and store this application form and other information submitted as part of the Khumo Programme application process. 4. I understand that it is the sole discretion of Phil 4 Consulting (Pty) Ltd and Assmang (Pty) Ltd – Khumani Iron Ore to select beneficiaries for the Khumo Programme and that the decision of the selection committee is final. 5. I understand that the completion and submission of this application form and related documentation does not automatically include my business in the Khumo Programme. 6. I understand that only successful applicants will be contacted. 7. I understand that this declaration is binding on my conscience, and that any inaccuracy or misrepresentation of facts is a criminal offence. Full name Position Date By selecting YES below I acknowledge that I understand the above declaration and accept this as a digital signature*YESNOThis is the end of section A. Please continue to section B below.SECTION C:DECLARATION OF CONFLICT OF INTEREST I , in my capacity as for and on behalf of (hereinafter referred to as the Company) signed on athereby declare that:1. no member, shareholder, partner, director and/ or employee of the Company or any of its affiliates, has a perceived, potential or actual conflict of interest that impacts the Company’s capacity to serve the best interest of Assmang (Pty) Ltd – Khumani Iron Ore and its direct or indirect subsidiaries. 2. Examples of such conflicts of interest include, but not limited to, the following: a. A direct or indirect financial interest in any of the companies comprising Assmang (Pty) Ltd – Khumani Iron Ore; b. A direct or indirect conflict of interest which may arise in respect of the implementation of development initiatives herewith applied for; c. Any affiliation with or family relation of any shareholder, director, or employee of any company comprising Assmang (Pty) Ltd – Khumani Iron Ore. If so, please state particulars of such perceived, potential or actual conflict of interest Areas of conflict if any, as required in 2.c aboveAny changes to a potential,perceived or actual conflict of interests declared by the Company during theimplementation of the enterprise development initiative shall be notified bythe Company completing a new declaration form and submitting it to theCorporate Social Responsibility Manager.NOTE: This declaration should besigned and dated by an authorised representative of the Company. Pleasestate the position of the person signing. Signed on* Full name and Surname of Signatory* Position held at the Applicant By selecting YES below I acknowledge that I understand the above DECLARATION OF CONFLICT OF INTEREST and accept this as a digital signature for the above declaration.*YESNOPlease submit the completed applicationform no later than 13:00 on Friday 28 January 2021 together with the required documentation. Once you completed this form, you will be taken to the UPLOAD AREA where you can submit all your required documentation. reCAPTCHASubmitReset
