PIXLEY ka SEME bismcrvuwemanry U-MASIPALA WENGINGQT Cater Road Priveatsak X1012 Private Bag X1012 DE AAR DEAAR 7000 7000 Telefoon (053) 631-0891/2-6 Telephone (053) 631-891/2-6 Faks (053) 631-2529 Fax (053) 681-2529 ‘mail ple telhomsa.et email: pelextrclhomsa.net APPLICATION FORM FOR EMPLOYMENT | This form must be completed in full, accurately and legibly. All substantial information relevant to a candidate ‘must be provided in this form. Any additional information may be provided on the CV. Candidates shortlisted for interviews may be requested to furnish additional information that will assist ‘municipalities to expedite recruitment and selection processes. All information received shall be treated with strict confidentiality and shall not be used for any other purpose than to assess the suitability of the applicant. ‘Name of the I. o we Distack Cay Municipality Printey Ka Se ck Maw cel Position/Post Applying | Foe Eaviconmental WHeall Proton PERSONAL DETAILS | Super MMeEMBY Tiaanay Saves we PRONDENCE TD or Passport Number BY V2VO7VSOFO Gender [Male |__| Female L xA_ Race African X'| White | Coloured Indian have an T x | Paes oe Yes No | Ifyes, elaborate disabi ' Ifnot, what is your Are you a SouthAfrican nationality? Yes No Citizen? Do you have a valid Yes No xX | work Permit? De id ion T Yee a crohns Name of professional | Membership membership with any Yes | No Expiry date z body Number professional body? Xx Hecsp rooreo 3 | lodeset‘CONTACT DETAILS Telephone number during office hours [SD Tas BEB ‘Mobile phone number O13 SAS S2ITSB Postal address | PRs I ANark [Code: GOkS Email Address [2enele pMthextu@ Grail -com Preferred language of communication [eral st ‘QUALIFICATIONS (please elaborate on your CV) Highest educational qualification obtained Name of the School Highest Grade ‘Year Obtained Nelabainiece iach Sdool | 12 250\ [Highest tertiary qualification obtained Name of Institution Name of a qualification) NOF level | Year Obtained Cone Unwersiis Of Jedwndks| Teh Envic “| 2020 ~ [Seale — | Mandosiiteaw University oF edadah Np Gute [2.004 WORK Experience (please elaborate on your CV) “| Employer (starting withthe most | Post From To Reason for leaving recent) held Month | Year| Month| Year Elcom M micipalit| S-EW-P | 12 oll ANU daic [keen (eal, \) Caste G HPL 01 [oid ta [eid Er of Contac] DISCIPLINARY RECORD | Have you been dismissed for “Yes ] No misconduct during the past ten (10) X years? | | Ifyes, Name of Municipality’ Employer ‘Type of a Misconduct! Transgression | Date of Resignation/ Disciplinary case finalised/Dismissal ‘Award! sanctionHave you been accused of an Yes No ] “alleged misconduct and resigned Xx | from your job pending finalisation of the disciptinary proceedings? CRIMINAL RECORD Have you been convicted of any criminal offence in a court of law Yes No during the past ten (10) years? x |Wyes, type of criminal act | Date criminal case finalised ‘Outcome/ Judgment REFERENCES (please elaborate on your CV) Name of - Relationship | Tel (office hours) | Cellphone Email Referee Number _ (asdBeae OS Most ELA Taye O3\ 32z 73 OGBI\1 22S ye, Nae OR SNBSW Ori SThyeny SYET WSII™ DECLARATION | Thereby declare that all the information provided in this application and any attachments in support thereof is to the best of my knowledge true and correct. | understand that any misrepresentation or failure to disclose any information may lead to my disqualification or termination of my employment contract, if appointed. Signature: Date iol 2) 202 We