APPLICANTS / INPLEMENTING AGENT FUNDING DECLARATION OF INTEREST FORM

In view of possible allegations of favouritism, should a grant be awarded to persons connected with or
related to NLC employees and its Board members, it is required that the applicants / implementing
agents declare their position in relation to the administrative and adjudicating authority, where the legal
person on whose behalf the application or request for funding is signed, has a relationship with
persons/a person who are/is involved in the administration and or adjudication of the application or
request for funding, or where it is known that such a relationship exists between the person or persons
for or on whose behalf the declarant acts and persons who are involved with the administration and or
adjudication of the grant application or request for funding.

In order to give effect to the above, the following questionnaire must be completed and
submitted with the application.

1. Full Name of applicant or his or her representative:

_______________________________________________________________________

2. Identity Number:

_______________________________________________________________________

3. Position occupied in the Company (director, trustee, shareholder):

_______________________________________________________________________

4. Registration Number:

_______________________________________________________________________

5. Do you, or any person connected with the applicant / implementing agent, have any relationship
(family, friend, other) with a person employed by the NLC? YES/NO
If yes, provide details

NLC EMPLOYEE
Full Name Identity Number Position within the Nature of Relationship
NLC
6. Do you or any of the directors / trustees / shareholders / members of the company have any
interest in any other related organisation with application or request for funding? in progress or
funded by the NLC? YES/NO

If yes, provide details

APPLICANT OR BENEFICIARY
Organisation Name Registration Director Name Nature of Relationship
Number

7. Are you or any of the directors / trustees / shareholders / members of the organisation exposed
to political person/s? YES/NO

If yes, provide details

APPLICANT OR BENEFICIARY
Director Name Political Person Name Nature of Relationship

8. Are you or any of the directors / trustees / shareholders / members of the organisation
government employees? YES/NO

If yes, provide details

APPLICANT OR BENEFICIARY
Director Name Name of department

9. CONSENT AND DECLARATION

The directors of above organisation hereby voluntarily provide consent for background checks to
be carried out on the organization and its directors. I/we agree that such assessment does not
infringe any of my/our fundamental rights. I/we accept that the background checks are part of
the screening process and that the NLC is under no obligation to fund above business.
Furthermore, I am/we are aware that a background checks involves compiling a comprehensive
 background and/or and personality profile and that one or more of the following methods are
used:
Complete ≥ R 500,000 R 501,000 - R ≤ R 5,000,000
5,000,000
1-6 1-7 1-10

1 Registration and DSD Reg Number:

compliance status CIPC Registration number:
of entity at: Masters Office Masters Reference No:
DSD, Masters
Office & CIPC

2 Directorship in other companies

3 Affiliation with any employee of the NLC (family/friends)
4 Verification of Deeds Office Property Owner:
Property Ownership ERF No :
for Infrastructure Township :
Projects if applying
for Infrastructure
Projects
5 Verification with Accounting Name and Surname:
Owner:
Accounting Bodies Professional
Professional Body :
[attached copy of Information
registration Professional Body Registration No :
certificate]
6 Verification of Banking Account holder
Owner:
Banking Details Details
Bank name
Branch code
Account number
Account type
7 Checking of records at the Fraud and Corruption related Criminal Record Centre of the SAPS
ompletion of GIP GIP 9 BIP questionnaire

I/WE HEREBY CONFIRM THAT ALL INFORMATION PROVIDED IN THIS APPLICATION IS CORRECT AND
CONSENT THAT MY INFORMATION CAN BE USED STRICTLY FOR THE PURPOSE OF ASSESSING ELIGIBILITY
FOR GRANT FUNDING. IF IT IS DETERMINED DURING OR AT ANY TIME AFTER THE EVALUATION PROCESS
THAT REQUESTED INFORMATION WAS WITHHELD FOR ANY REASON OR THAT FALSE INFORMATION WAS
PROVIDED IT MAY IMPACT NEGATIVELY ON THE OUTCOME OF THE PROCESS.

(To be completed by all Directors of the Organisation)

Director/member name ID number Signature