APPLICATION FOR REGISTRATION ON DATA BASE Bergrivier Municipality – Bergrivier, Western Cape




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.