APPLICATION
APPLICANT INFORMATION
FIRST NAME(S) SURNAME IDENTITY NR/PASSPORT NR DATE OF BIRTH
RESIDENTIAL ADDRESS
PHONE 1 PHONE 2 EMAIL ADDRESS
Gender *Ethnicity
South African Citizen Yes or No: Nationality (if not SA)
*Disability Yes or No: If yes, please specify?
Driver’s License Yes or No: If yes, please specify Code?
Criminal Offences?
(this may Include any pending Yes or No: If yes, please provide details
matters)
Any Medical Conditions? Yes or No: If yes, please provide details
Marital Status Languages
POSITION AVAILABLE
What position are you applying for?
How did you learn about the position being available?
Are you willing to relocate?
EMPLOYMENT TYPE DESIRED CURRENT SALARY SALARY DESIRED AVAILABLE START DATE
Full Time / Part Time / Temp
EDUCATION
SCHOOL NAME QUALIFICATION COMPLETED Y or N? YEAR
OTHER /
APPLICABLE
TRAINING
APPLICABLE
SKILLS /
PROFICIENCIES
PROFESSIONAL
AFFILIATIONS
EMPLOYMENT HISTORY Most recent employer first
EMPLOYER NAME POSITION HELD START DATE END DATE
SUPERVISOR NAME CONTACT NUMBER EMAIL ADDRESS MAY WE CONTACT? Y or N
REASON FOR LEAVING
EMPLOYER NAME POSITION HELD START DATE END DATE
SUPERVISOR NAME CONTACT NUMBER EMAIL ADDRESS MAY WE CONTACT? Y or N
REASON FOR LEAVING
EMPLOYER NAME POSITION HELD START DATE END DATE
SUPERVISOR NAME CONTACT NUMBER EMAIL ADDRESS MAY WE CONTACT? Y or N
REASON FOR LEAVING
EMPLOYER NAME POSITION HELD START DATE END DATE
SUPERVISOR NAME CONTACT NUMBER EMAIL ADDRESS MAY WE CONTACT? Y or N
REASON FOR LEAVING
CONSENT and AGREEMENT
(* For Legal or Statistical purposes in terms of the Employment Equity Act)
I certify that the information given on this application is complete and correct. I consent to the contact of former employers/institutions listed
above.
I hereby declare that all details in this document and supporting documents which I have supplied are correct and 100% accurate. I accept that
non-disclosure of information will result in a withdrawal of any offer or constitute ground for dismissal by any employer / potential employer. I agree
not to disclose any confidential information supplied by AJ Roodt Consulting (Pty) Ltd, relating to the position/s under discussion to any third party for
commercial gain.
Please be advised that Credit and Criminal Checks may be conducted on applicants.
Your privacy is very important us, and all personal information collected will be handled in a lawful, justifiable and reasonable manner. We will be as
open and transparent as possible with you as to how your personal information is handled.
For the purposes of this application form, it constitutes an acknowledgement and consent form, "personal information" is any form of information that
is identifiable with you, which may include but is not limited to your, name, mailing address, phone number, email address, employment history, and
financial history, as more fully defined in the Protection of Personal Information Act No. 4 of 2013 ("POPIA").
You hereby consent and duly authorize AJ Roodt Consulting (Pty) Ltd, to market and provide relevant personal information to potential Employers
for the purposes of review and application for any position available for which AJ Roodt Consulting (Pty) Ltd has been appointed and contracted to
assist with recruitment.
Furthermore, signature hereto constitutes agreement to any background verification checks deemed necessary and required for any position
applied for, including verification of Identity, Credit and Criminal Checks as well as verifications of any qualifications, as and when required.
Please include the following documents when submitting completed Application Form:
• Full and detailed Curriculum Vitae
• Copy of Identity Document/Card/Passport
• Copy of Matric Certificate
• Any other qualifications achieved
• Driver’s License
SIGNATURE
PRINTED NAME SIGNATURE DATE
Consent Form/Indemnity Form
CANDIDATE PERSONAL INFORMATION - To be completed by the Candidate
****PLEASE ENSURE ALL INFORMATION IS IN A CLEAR NEAT HANDWRITING AS CSS MAY REJECT THE INDEMNITY FORM, IF HANDWRITING IS
UNCLEAR ****
Surname:
Full Names:
Maiden Surname:
South African ID Number:
Date of Birth: / /
Nationality: Passport Number:
Physical Address:
House Number: Street
Name: Suburb:
City:
Cell Number:
Email Address:
VERIFICATIONS REQUIRED - Please tick the necessary required Verifications Only
Criminal Background Check TransUnion Credit Check/ ITC
ID Verification *Secondary Qualification (Matric)
Driver License and PDP *Tertiary Qualification
*Please attach a clear copy of the certificates that need to be verified
INDEMNITY DECLARATION - To be read and signed by the Candidate
I hereby authorize The Company's duly authorized verification agent, Civil Specialised Services ("CSS"), to forward any personal information as well as any
information that I have provided in support of my application to verifications information suppliers acting on behalf of CSS, Including but not limited to
the South African Police Services/AFISwitch, the Government of RSA and any education, training credit bureau and fraud prevention organizations for the
purpose of verifying my person credentials and records.
Authorized credential verification types include, but are not limited to, educational qualifications, employment references, consumer credit, criminal
record, drivers' license and fraud prevention checks.
I authorize CSS's verification information suppliers to furnish information regarding my credentials, whether claimed or not, to CSS and The Company. I
unconditionally indemnify CSS and its verifications information suppliers against any liability that may result in furnishing information in this regard.
I understand that it is a condition of CSS verification information suppliers that this information is furnished by them solely for the purpose of my
proposed/continuation of employment via the offices of The Company and that any information that is furnished to The Company and CSS will be
disclosed to me before a decision is made on my continued employment or application for employment. Furthermore, I authorize CSS to host my
fingerprints and, upon request and with my consent, to release criminal results to other organisations.
All signatories to this document agree that CSS will NOT be held liable for the content, factual correctness or accuracy of any Supplier Data supplied to CSS
for The Company by CSS's suppliers. The Company and the Candidate hereby indemnifies and holds CSS harmless against any loss arising from neglect or
damage in procuring, communication or failing to communicate information to The Company
CANDIDATE SIGNATURE DATE
As the enquiring agent of the Company, and in the case that this form instructs CSS to provide consumers credit information, I hereby state that I
understand the provisions of the National Credit Act (34 of 2005), section 70(2)(g), and Regulations made in terms of the Act, section 18(4) and (5)
AGENT NAME AGENT SIGNATURE DATE
This document is to be kept in the candidates file - CSS does not keep these records Updated - 29/06/2023
PAGE 1 OF 1 EEA1
DEPARTMENT OF LABOUR
DECLARATION BY EMPLOYEE
(Confidential)
PLEASE READ
THIS FIRST
1. Name of employee:
Purpose of this form
2. Employee workplace No:
This form is used to obtain (This is the number that an employer/company/organization uses to identify an employee in the
workplace.)
information from
employees for the purpose
of assisting employers with 3. Please indicate to which categories you belong with an ‘X’
conducting an analysis on below:
the workforce profile.
Employers should use this Male Female
form to ascertain which
employees are from
designated groups in terms
of the Employment Equity
Act, 55 of 1998. African Coloured Indian White
Who fills in this form
Employees should fill in this
form.
Instructions Foreign National
Employers must ensure that the If you are not a citizen by birth, please indicate the date you acquired your
contents of this form remain
confidential, and that it is
only used to comply with the citizenship: …………………….
Employment Equity Act, 55 of
1998.
‘People with disabilities’ are Person with a disability
defined in the Act as people
who have long-term or
recurring physical or mental If yes, specify nature of disability:
impairments, which
substantially limits their
prospects of entering into, or
advancement in employment.
Please note that people have
the right to disclose or not to 4. I verify that the above information is true and correct.
disclose their disability.
Signed:
Employee
Date:
