Black Economic Empowerment Questionnaire
Particulars of Applicant
Registered name of the Supplier
If the application is in an Individual capacity, please state your initials and surname.
Trading name (if applicable)
VAT registration number
Income Tax reference number
PAYE reference number
Part A: General Information
1. The information provided in this questionnaire will be treated as confidential and will not be disclosed to any third party.
2. The information will be used only for the purpose of assessing your company in terms of our Black Economic Empowerment Policy.
3. ABC (Pty) Ltd reserves the right to request additional information or documents, or to perform audit procedures to substantiate or verify any of the answers provided in the question.
4. A copy of the completed questionnaire must be signed on behalf of your business by a duly authorised signatory.
5. Certified copies of requested documents are to be submitted as part of this information pack.
Particulars of contact person
Initials and Surname
Business telephone number
ID or Company/Close
Corporation/Trust registered number
Part B: Direct Empowerment
1. Equity ownership
a) What percentage equity is owned by blacks1 % owned
b) What percentage is owned by black women % owned
c) What percentage equity is owned by people with disabilities2 % owned
a) What % voting rights is controlled by blacks? % control
b) What % voting rights is controlled by black women? % control
c) What % economic interest3 is held by blacks? % control
d) What % economic interest is held by black women? % control
2.1 What is the actual number of executive management positions in your company?
2.2 What percentage of your company’s executive management positions is occupied by black men? %
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