VA1HARMONY GOLD MINING COMPANY LIMITED Randfontein 1760 Vendor Administration Department Tel: (011) 41140 – 30/31/34 Harmony Gold Mining Company Limited (Registration number 1950/038232/06) VENDOR FORM Applications for new Vendors require the completion of two forms, namely the VA1 Vendor Form to be completed by a Harmony representative that motivates the need for a new supplier and the VA2 Supplier Form to be completed by the supplier. The VA1 Vendor Form is also utilized to request the linking of an existing Vendor to a Harmony Business Unit, request the Activation of a Vendor previously de-activated or request a Vendor to be loaded for emergency usage.` Type of Application: New Application: Motivation for a Sole Supplier After-Event Emergency New Vendor Vendor Vendor Maintenance: Activate a Vendor Link a Vendor to a (previously deBusiness Unit activated) Based on the type of application the following sections should be completed. Motivation for a New Section A, Section B, Section C Vendor Activate a Vendor Section A (Supplier Company Name and Motivation to activate a Vendor), Section B, (previously de-activated) Section C Link a Vendor to a Business Section A (up to Supplier Company Name) and Section D Unit Emergency Vendor Section A , Section B, Section E Sole Supplier Section A, Section B, Section C. The Supplier Information form (VA2) should be completed by the supplier and handed in with the Vendor Form (VA1). Proof of ‘Sole’ Supplier status must be submitted along with the Vendor From. After the Event Vendor Section A, Section B, Section C. The Supplier Information form (VA2) should be completed by the supplier and handed in with the Vendor Form (VA1). Please ensure that the ‘Motivation for loading an After the Event Vendor’ in Section A is completed. Section A – Motivation for a New Vendor (Only to be completed if the ‘Motivation for new Vendor’ or ‘Activate a Vendor’ were selected at the top of the form.) This section captures the detail of the Harmony unit that requires the services of a new vendor. Harmony Business Unit Harmony Representative Name Harmony Representative Position Directors: PT Motsepe* (Chairman), GP Briggs (Chief Executive), HO Meyer (Financial Director), HE MAshego (Executive Director), F abbott*, JA Chissano*#, FFT de Buck*, Dr CM Diarra*##, KV Dicks*, Dr DS Lushaba*, CE Markus*, MJ Motloba*, CML Savage*, AJ Wilkens* *Non - Executive; #Mozambican, *##US/Mall Citizen Secretary: Registration Number: NY Maluleke 1950/038232/06 CE Markus*. breakers and grinders Drilling equipment Electric Motors Engineering services Heating. #Mozambican. HO Meyer (Financial Director). MJ Motloba*. Dr DS Lushaba*.g. CML Savage*. Dr CM Diarra*##. *##US/Mall Citizen Secretary: Registration Number: NY Maluleke 1950/038232/06 . why can the product not be sourced from existing vendors?) Motivation to Activate a Vendor (if applicable) Motivation for loading an ‘After the Event Vendor’.VA1 HARMONY GOLD MINING COMPANY LIMITED Randfontein 1760 Vendor Administration Department Tel: (011) 41140 – 30/31/34 Harmony Gold Mining Company Limited (Registration number 1950/038232/06) Contact Number Supplier Company Name Estimated Annual Spend with the supplier Motivation for New Vendor (E. F abbott*. the requestor should complete this motivation) Section B – Product List Type A Products (Select the products to be supplied by the proposed vendor) Chemicals Conveyors and Accessories Crushers. what product/service is required. (In the event that the services of a non-approved vendor was utilized. KV Dicks*. what value can they add. why is it required. FFT de Buck*. GP Briggs (Chief Executive). AJ Wilkens* *Non . ventilation and air circulation Hoisting and Scraping Equipment G.Executive.I instrumentation PPE and safety clothing Pumps and related equipment Railway and tramway machinery and related equipment Directors: PT Motsepe* (Chairman). JA Chissano*#.D. HE MAshego (Executive Director). food and lodging services Underground support services Vehicles – supply and/or maintenance Welding services If none of the above. #Mozambican. Category 2 Supplier Category 3 Supplier Category 4 Supplier Directors: PT Motsepe* (Chairman). JA Chissano*#.VA1 HARMONY GOLD MINING COMPANY LIMITED Randfontein 1760 Vendor Administration Department Tel: (011) 41140 – 30/31/34 Harmony Gold Mining Company Limited (Registration number 1950/038232/06) Explosives Fastener equipment Maintenance. refining and forming equipment Mining and engineering services Oils. FFT de Buck*. Repair and Overhauling Safety equipment Seismic monitoring equipment and services Type B Products Building and construction material Chains Cleaning material Consultancy services Contract labour Electrical Systems and Components Financial and Insurance Services Food and Beverage Products Hiring of Equipment Information Technology Mail and storage facilities Medical aid equipment Metal smelting. Dr DS Lushaba*. *##US/Mall Citizen Secretary: Registration Number: NY Maluleke 1950/038232/06 . F abbott*. please describe product/service: Section C – Classification (The below chart will assist you in determining the Supplier Category) Category 1 Supplier If product/service is only in the Type B Product List and no product in Type A Product List was selected and the Estimated Annual Spend with Harmony is less than R300 000. CML Savage*. GP Briggs (Chief Executive). HE MAshego (Executive Director). HO Meyer (Financial Director). fuels and lubricants Organizations and Club services Pipes and Tubing supplies Processing of scrap products Sampling equipment Security equipment Stationery and office supplies Steel products Telecommunication equipment Tools Training and education services Transportation services Treatment of Woodchips Treatment of surface sources Travel. If product/service is only in the Type B Product List and no product in Type A Product List was selected and the Estimated Annual Spend with Harmony is greater than R300 000. KV Dicks*. Dr CM Diarra*##. If any product/service in Type A Product List was selected and the Estimated Annual Spend with Harmony is less than R300 000. MJ Motloba*. AJ Wilkens* *Non .Executive. CE Markus*. If any product/service in Type A Product List was selected and the Estimated Annual Spend with Harmony is greater than R300 000. Dr DS Lushaba*. Category 1 Supplier BEE certificate (if available) Category 2 Supplier BEE certificate (if available) Tax Clearance Certificate Category 3 Supplier Category 4 Supplier BEE certificate (if available) Risk Assessment BEE certificate (if available) Tax Clearance Certificate Risk Assessment Section D – Link a Vendor to a Business Unit Vendor Number Business Unit ARM EOH KG AVG EVA REL CEN SERV FG SAMC ELK HGM RU Section E – Emergency Vendor Information Banking Details Account Name Account Number Bank Bank Branch Code Directors: PT Motsepe* (Chairman).VA1 HARMONY GOLD MINING COMPANY LIMITED Randfontein 1760 Vendor Administration Department Tel: (011) 41140 – 30/31/34 Harmony Gold Mining Company Limited (Registration number 1950/038232/06) Based on the Category of supplier. MJ Motloba*. HE MAshego (Executive Director). KV Dicks*. Without the complete set of information the application will not be processed. CE Markus*. FFT de Buck*. GP Briggs (Chief Executive). Dr CM Diarra*##.Executive. the below documentation need to be submitted by the supplier to Harmony should the motivation be approved. JA Chissano*#. #Mozambican. F abbott*. AJ Wilkens* *Non . *##US/Mall Citizen Secretary: Registration Number: NY Maluleke 1950/038232/06 . HO Meyer (Financial Director). CML Savage*. KV Dicks*. MJ Motloba*.Executive. FFT de Buck*.VA1 HARMONY GOLD MINING COMPANY LIMITED Randfontein 1760 Vendor Administration Department Tel: (011) 41140 – 30/31/34 Harmony Gold Mining Company Limited (Registration number 1950/038232/06) Harmony Representative: Signed at (Place) __________________________________ on (Date) ________________________ For (Harmony) ____________________________________________________________________ Initials and Surname: Position in Company: ______________________________________ ______________________________________ Signature: HOD: _____________________________________ Initials and Surname: ______________________________________ ______________________________________ Date ________________________ Position in Company: Signature: _____________________________________ Directors: PT Motsepe* (Chairman). CML Savage*. Dr DS Lushaba*. Dr CM Diarra*##. GP Briggs (Chief Executive). CE Markus*. #Mozambican. AJ Wilkens* *Non . HE MAshego (Executive Director). F abbott*. JA Chissano*#. *##US/Mall Citizen Secretary: Registration Number: NY Maluleke 1950/038232/06 . HO Meyer (Financial Director).