Munisipaliteit BERGRIVIER Municipality
Rig alle korrespondensie aan: (022) 913 1126
(022) 913 1380
Die Munisipale Bestuurder
Address all correspondence to: E-pos/E-mail:
The Municipal Manager bergmun@telkomsa.net
60
PIKETBERG Webtuiste/Website:
7320
www.bergmun.org.za
AANSOEK OM REGISTRASIE OP DATABASIS
APPLICATION FOR REGISTRATION ON DATA BASE
(Dui aan met X / Mark with X)
ALGEMENE WERK/ KLERKLIKE WERK/
GENERAL WORK CLERICAL WORK
STRENG PRIVAAT EN VERTROULIK
STRICTLY PRIVATE AND CONFIDENTIAL
BELANGRIK / IMPORTANT
Geliewe hierdie vorm te voltooi en terug te stuur aan:Please complete this form and return to:
Die Menslike Hulpbrondienste Departement, Posbus 60, PIKETBERG, 7320
The Human Resource Department, P O Box 60, PIKETBERG, 7320
VOLLE NAAM EN VAN (APPLIKANT)
FULL NAME AND SURNAME (APPLICANT)
_______________________________________________________________
AANSOEK OM REGISTRASIE OP DATABASIS: TYDELIKE PERSONEEL
APPLICATION FOR REGISTRATION ON DATA BASE: TEMPORARY STAFF
DATUM / DATE : ______________________________________
(2)
1. ADRES
ADDRESS : ______________________________________
_______________________________________
_______________________________________
2. TELEFOONNOMMER: Woning Werk
TELEPHONE NUMBER: Residence: _________________ Office: __________________
3. GEBOORTEDATUM
DATE OF BIRTH : _________________________________
4. IDENTITEITSNOMMER
IDENTITY NUMBER : _________________________________
5. (Dui aan met X / Mark with X)
ONGETROUD / SINGLE GETROUD / MARRIED GESKEI / DIVORCED
MANLIK / MALE VROULIK / FEMALE
SWART / BLACK BRUIN / COLOURED
WIT / WHITE INDIËR / INDIAN
S A BURGER (van geboorte) / S A CITIZEN (by birth)
S A BURGER (deur naturalisasie) / S A CITIZEN (by naturalisation)
VREEMDELING / ALIEN
7. GESONDHEIDSTOESTAND
CONDITION OF HEALTH : _________________________________
- Het u enige liggaamlike of geestelike gebreke of ernstige of chroniese siektes?
- Do you have any physical or mental disorders or serious or chronic diseases?
Indien wel, verstrek besonderhede
If so, furnish particulars : ____________________________________
_____________________________________________________________________________
8. KWALIFIKASIES / QUALIFICATIONS
(A) SKOOLOPLEIDING / SCHOOL EDUCATION
GRAAD DATUM INRIGTING VAKKE GESLAAG
GRADE DATE INSTITUTION SUBJECTS PASSED
(B) TERSIÊRE OPLEIDING / TERTIARY EDUCATION
GRAAD / DIPLOMA DATUM INRIGTING VAKKE GESLAAG
DEGREE / DIPLOMA DATE INSTITUTION SUBJECTS PASSED
(3)
(C) MELD BESONDERHEDE VAN ENIGE ANDER KWALIFIKASIES
STATE PARTICULARS OF ANY OTHER QUALIFICATIONS
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
BESTUURDERSLISENSIE: JA/NEE KODE: ___________________________
DRIVERSLICENCE: YES/ NO______________ CODE: ___________________________
9. TAALVAARDIGHEID / LANGUAGE PROFICIENCY (Dui aan met X / Mark with X)
TAAL / LANGUAGE PRAAT / SPEAK LEES / READ SKRYF / WRITE
AFRIKAANS
ENGELS / ENGLISH
ANDER / OTHER
10. WERKSONDERVINDING / WORK EXPERIENCE
- Begin met huidige/jongste werksondervinding
- Begin with recent work experience
INSTANSIE/COMPANY POSISIE BEKLEE/ TYDPERK/ REDE VIR DIENS-
POSITION PERIOD BEËINDIGING/ REASON
FOR TERMINATION OF
SERVICE
11. ALGEMEEN/ GENERAL (Dui aan met X / Mark with X)
Are any of your relatives or acquaintances employed by the Yes No
council or a councillor? Ja Nee
Is enige van u familie of kennisse in diens van die raad of ‘n
raadslid?
If “yes”, state name, department & relationship
Indien wel, meld naam, departement & verwantskap
Have you ever been convicted of a criminal offence? Yes No
Is u voorheen skuldig bevind aan ‘n kriminele oortreding? Ja Nee
Hierby word verklaar dat die inligting wat hierbo verskaf is, in alle opsigte juis en waar is.
I hereby declare that all information furnished above are in all respects correct and true.
HANDTEKENING/SIGNATURE: _____________________________________________
DATUM/DATE: _____________________________________________
NOTA /NOTE : Enige valse verklarings kan lei tot summiere diskwalifikasie.
Any false/untrue statements will lead to summarily disqualification.