Approved: 15/03/2023

Council res: R22/3-23

ANNEXURE C: APPLICATION FORM FOR

EMPLOYMENT
IMPORTANT NOTES TO APPLICANT:
1. The purpose of this form is to assist a municipality in selecting suitable candidates for an advertised post.
2. 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. No applications will be considered if the application form is not attached.
3. Candidates shortlisted for interviews may be requested to furnish additional information that will assist municipalities to expedite recruitment and selection processes. By completing this form, the
applicant grants the municipality permission to access information during the vetting and screening process.
4. 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.
5. This form is designed to assist municipality with the recruitment, selection and appointment of staff members in terms of the Municipal Systems Act, 2000 (Act No. 32 of 2000)
6. Applications/Supporting documents larger that 2MB sent via email are not accommodated.
7. For the implementation of the Employment Equity Act, candidates are encouraged to indicate their race, gender and disability.
8. No late applications will be considered.
9. Further communication will be limited to shortlisted candidates. If you do not receive a response within 3 (three) months of the closing date, please consider your application unsuccessful.
10. All appointments are subject to a medical assessment, criminal record and reference checks from previous and current employer(s).
11. The Council beholds the right not to make an appointment.
12. All appointments will be made in terms for the Local Government Municipal Staff Regulations.

Advertised post applying for Reservist Fire Fighter

Notice service period immediate
PERSONAL DETAILS

Surname Page
First Names Blaine Jarod
ID or Passport Number 0407285438088
Gender Male X Female

Race African White Coloured X Indian

Do you have a disability? Yes No

X If yes, elaborate

If not, what is
your nationality?
Are you a South African Citizen? x
Yes No
Do you have a valid Yes No
work Permit?
Do you hold a professional membership Name of Membership Number Expiry date
professional body
with any professional body? Yes No

CONTACT DETAILS

Telephone number during office hours ( +27 ) 71 250 2584

Mobile phone number 071 250 2584
Postal address 4 Blue Road, Blue Lagoon Estate, Langebaan
Postal Code: 7357
Email Address [email protected]
Preferred language of communication English

QUALIFICATIONS (please elaborate on your CV)

Highest educational qualification obtained

Name of the School Highest Grade Year obtained

Longacres Private School 77% 2022

 Approved: 15/03/2023
Council res: R22/3-23

Highest tertiary qualification obtained

N F
Name of Institution Name of a qualification Year obtained
level

Longacres Private School National Senior Certificate 4 2022

WORK EXPERIENCE (please elaborate on your CV)

From To
Employer (starting with the most Post
held Reason for leaving
recent) Month Year Month Year

Freelancer December 2022 April 2023

Cameron Bramley
Salesperson

COMPETENCIES
List all competencies as advertised here (additional page may EXCELLENT REQUIRES
be added if more explanation is required) COMPETENT
DEVELOPMENT
Crossfit athlete, sprinter and powerllifter. Physical and mental resilience x
x
Emergency medical care.
Self-motivated and determined and the ability of motivating others.
x
x
Attended the Die Burger's 63rd WCED Youth Leadership Conference,
representation of interpersonal skills, professionalism and teamwork and morality
and communication skills.
x
Attention to detail and consideration of alternative measures.
x
DISCIPLINARY RECORD

Have you been dismissed for misconduct during the past ten (10) years? Yes No
x
If yes, Name of Municipality/ Employer

Type of a Misconduct/ Transgression

Date of Resignation/ Disciplinary case finalised/Dismissal

Award/ sanction

Have you been accused of an alleged misconduct and resigned from

your job pending finalisation of the disciplinary?
proceedings?
Yes No x

CRIMINAL RECORD
Have you been convicted of any criminal offence in a court of law during the past ten (10) years? Yes No x
If yes, type of criminal act

Date criminal case finalised

Outcome/ Judgment
 Approved: 15/03/2023
Council res: R22/3-23

REFERENCES (please elaborate on your CV)

Name of Referee Relationship Tel (office hours) Cellphone Number Email

Heike Thumser former educator 064 905 7392

Cameron Bradley former employer 076 349 2583

DECLARATION
• I hereby 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.
• I understand that any misrepresentation or failure to disclose any information may lead to my disqualification or termination of my employment contract, if
appointed.
• Saldanha Bay Municipality complies with the Protection of Personal Information Act, Act 4 of 2013(POPIA), by submitting your application for a position at
Saldanha Bay Municipality you are consenting that the personal information submitted as part of your application may be used during vetting and screening
process.

Signature: Date: 03/05/23