BUSINESS OWNERS DETAILS:
Landlord's Details (If Rented)
(Confirmation of BEE Level must be available on request)
The annual turnover of the above-mentioned entity was less than R10,000,000 (Ten Million Rand) in terms of the most recent audited financial statements or factual finding from an independent review, qualifying the entity as a Exempt Micro Enterprise (EME). I also confirm that the company has a Black (as defined per the B-BBEE Codes of Good Practice) shareholding as follows:
Please Confirm on the below table the B-BBEE Level Contributor, by ticking the applicable box.
As per the Broad-Based Black Economic Empowerment Act 53 of 2003, as Amended by Act No 46 of 2013 “Black People”, is a generic term which means African, Coloured and Indian – (a) who are citizens of the Republic of South Africa by birth or descent; or (b) who became citizens of the Republic of South Africa by naturalization. before 27 April 1994; or ii. on or after 27 April 1994 and who would have been entitled to acquire citizenship by naturalization prior to that date;”
(Annual Financial Statements must be available on request)
Please provide the names & Contact Details of 3 x Current Suppliers
TRADE REFERENCE 1:
TRADE REFERENCE 2:
TRADE REFERENCE 3:
CONSENT FOR THE USE OF PERSONAL INFORMATION
I hereby authorize the Company’s duly authorized verification agent, to access my Personal Information and conduct background screening checks, including, but not limited to, CIPC Registration Verification, credit / supplier references, bank verification, criminal record, fraud prevention, ID verification, and all social media accounts linked/associated/known to me of which I am a user/member of.
I consent to requests for consumer credit information to be released for the purpose of this application.
I understand that verification requests form part of the background screening process and:
that requests for credit information from Credit Bureaus will only be conducted under the regulations defined as per the National Credit Act (NCA).
Data obtained from the Financial Sector Conduct Authority (FSCA) serve only for the purpose to determine the fitness and propriety as envisaged in the Financial Advisory & Intermediary Services (FAIS) Act.
I acknowledge that any Personal Information supplied to the Company is provided voluntarily and that the Company may not be able to comply with its obligations if the correct Personal Information is not supplied.
I understand that privacy is important to the Responsible Parties and the Responsible Parties will use reasonable efforts in order to ensure that any Personal Information in their possession or processed
on their behalf is kept confidential, stored in a secure manner and processed in terms of South African law and or applicable Data Protection Legislation, for the purposes I have authorised.
I warrant that all information, including Personal Information, supplied to the Company is accurate and current and agree to correct and update such information when necessary.
By submitting any Personal Information to the Company in any form I acknowledge that such conduct constitutes a reasonable unconditional, specific and voluntary consent to the processing of such Personal Information in the following manner by the Company and/or verification information suppliers:
I take note that if the Responsible Party has utilised the Personal Information contrary to the Privacy and Data Protection Conditions, I may first resolve any concerns with that Responsible Party. If I am
not satisfied with such process, I have the right to lodge a complaint with the Information Regulator.
A copy of Personal Information kept by the Responsible Parties will be furnished to me upon request in terms of the provisions of POPI or the NCA and I understand that I may dispute any information in the record provided.
I unconditionally agree to indemnify the Responsible Parties, and Verification Information Suppliers, acting in good faith in taking reasonable steps to process my personal information lawfully, against
any liability that may result from the processing of my personal information. This includes unintentional disclosures of such personal information to, or access by unauthorized persons, and/or any reliance which may inadvertently be placed on inaccurate, misleading, or outdated personal information, provided to the Company by myself or by a third party in respect of me.
In authorizing the search/s referred to above, I confirm that I have not been forced/ coerced into signing and supplying the above information.