Santam Online Form

SANTAM REQUESTOR DETAIL FOR INTERNAL USE ONLY Please note that your details will not be laoded if we do not receive this form from a Santam Requestor / DATE CREATE A NEW CLAIM SUPPLIER OR DD/MM/YYYY AMEND AN EXISTING CLAIM SUPPLIER EXISTING JDE ADDRESS BOOK NO. A JDE form will not be accepted without a completed signed questionnaire plus a copy of your BBBEE Certificate I the undersigned hereby guarantee that I have the authority to sign this document and that the above information is true and correct. Furthermore I declare that should the supplier or bank details be found to be incorrect Santam will not be held liable for any loss incurred as a result of the use of that information. I also give my consent and authorise Santam Ltd to perform a credit assessment on and/or the Supplier and/or our members shareholders owners or employees. Annexure D2 p*1 CLAIM SUPPLIER INFORMATION - JDE FORM CREATE / AMEND A RECORD IN JDE ADDRESS BOOK Motor Related Supplier MBR / Panelbeater / Tow Operator FAX THE COMPLETED SIGNED FORM BACK TO THE PROCUREMENT JDE SUPPLIER TEAM ON 021 915 7342 OR 021 914 0787. NAME OF SANTAM REQUESTOR CONTACT NUMBER TIER GROUP SOURCING CONTRACT OFFICER NSR ASR MSR Supplier Contracted SANTAM BRANCH NO. NO YES SUPPLIER INFORMATION LEGAL ENTITY NAME Registered Name TRADE NAME PARENT COMPANY if applicable Closed Corp ENTITY TYPE Private Co Sole Prop Incorpo rated Partner ship Trust COMPANY REGISTRATION NO. Please attach Documents Public Co Listed Unlisted Ltd Liability Art 21 Other IF NOT REGISTERED ID NO OF OWNER / PTN IS CO. VAT REGISTERED IF YES PLEASE SUPPLY VAT NO Please attach Vat Clearence Certificate NATURE OF SERVICE Cars / LDV s MOTOR BODY REPAIRS Heavy Vehicles Motorbikes Light Vehicle Towing TYPE OF TOW SERVICES Are you a member of a association Yes No Caravans N/A OTHER Salvage Description If other Farm Vehicles / Implements Both Mechanical REPAIRER STATUS Boats Dealer OTHER Motor Vehicle Related Trailers Digital Assessment Capability IF YES SUPPLY NAME OF ASSOCIATION CONTACT DETAILS COUNTRY TELEPHONE NUMBER AREA CODE NUMBER RSA NAMIBIA FAX E-MAIL INTERN* CODE FAX NUMBER AFTER HOURS Only if 24h service is offered ORDER SEND / CORRESPONDENCE METHOD ORDER E-MAIL ADDRESS POSTAL ADDRESS POSTAL CODE SUBURB / CITY PHYSICAL ADDRESS Domicilium Citandi Et Executandi CITY SUBURB West Cape PROVINCE Freestate Gauteng KZ Natal East Cape Limpopo North Cape North West Mpumalanga PAYMENT DETAILS MAXIMUM AGREED MARK-UP Only for Motor Parts CHOICE OF PAYMENT TERMS 20. 00 22. 50 14 DAYS 5 DISCOUNT 25. 00 27. 50 Other See Agreement 21 DAYS 2. 5 DISCOUNT 30 DAYS NET MARK UP ON ALL NETT PARTS INVOICES DISCOUNT OFFERED TO RECEIVE EARLIER PMT Please read Terms Conditions attached sign BANK DETAILS Bank Details will only be accepted if form is Signed by Supplier OR accompanied by a Confirmation fax on letterhead / cancelled cheque BANK NAME BUSINESS ACCOUNT NAME BRANCH CODE BANK ACCOUNT NUMBER CURRENT / CHEQUE TYPE OF ACCOUNT SAVINGS TRANSMISSION BROAD-BASED BLACK ECONOMIC EMPOWERMENT BBBEE Please ensure that you complete the attached 1-page Financial Sector Charter Procurement Questionnaire.