ANNEXURE C APPLICATION FORM FOR …

1 ANNEXURE CAPPLICATION form FOR EMPLOYMENTTERMS AND purpose of this form is to assist a municipality in selecting suitable candidates for an form must be completed in full, accurately and legibly. All substantial information relevant to acandidate must be provided in this form . Any additional information may be provided on the shortlisted for interviews may be requested to furnish additional information that will assistmunicipalities to expedite recruitment and selection information received will be treated with strictly confidentiality and will not be used for any otherpurpose than to assess the suitability of the form is designed to assist municipality with the recruitment, selection and appointment of seniormanagers in terms of the Local Government: Municipal Systems Act, 2000 (Act No. 32 of 2000).A. DETAILS OF THE ADVERTISED POST (as reflected in the advert)Advertised post applying forReference numberName of MunicipalityNotice service periodB.

2 PERSONAL DETAILSS urnameFirst NamesID or Passport NumberRaceAfricanI ColouredIndianWhiteGenderFemale MaleDo you have a disability?YesNoIf yes, elaborateAre a South African citizen?YesNoIf no, what is yourNationality?Work Permit Number (if any):Do you hold any political office in a political party, whether in a permanent, temporaryor acting capacity? If yes, provide information Party:IPosition:IExpiry date:Do you hold a professional membership with any professional body? If yes, provideinformation belowYesNoProfessional Body:IMembership Number:fExpiry date:C. CONTACT DETAILSP referred language forcorrespondence?Telephone number duringoffice hoursPreferred method forcorrespondence (Mark withan X)PostE-mailFaxCorrespondence contactdetails (in terms of above)STAATSKOERANT, 17 JANUARIE 2014No. 3724545 This gazette is also available free online at QUALIFICATIONS (Additional information may be provided on your CV)Name of School / TechnicalCollegeHighest Qualification ObtainedYear ObtainedName of InstitutionName of QualificationNQF LevelYear ObtainedE.

3 WORK EXPERIENCE (Additional information may be provided on your CV)Employer (starting withthe most recent)PositionFromToReason forleavingMMYYMMYYIf you were previously employed in Local Government, indcatewhether any condition exists that prevents your re- employment :YesNoIf yes, provide the name ofthe previous employingmunicipality:F. DISCIPLINARY RECORDHave you been dismissed for misconduct on or after 5 July 2011?YesNoIf yes, Name of Municipality/ Institution:Type of a Misconduct/ TransgressionDate of Resignation/ Disciplinary case finalisedAward/ sanctionDid you resign from your job on or after 5 July 2011 pendingfinalisation of the disciplinary proceedings? If yes, provide detailson a separate CRIMINAL RECORDWere you convicted of a criminal offence involving financialmisconduct, fraud or corruption on or after 5 July 2011? If yes,provide details on a separate yes, type of criminal actDate criminal case finalisedOutcome/ JudgmentH.

4 REFERENCEName of RefereeRelationshipTel (office hours)Cellphone declare that all the information provided in this APPLICATION and any attachments in support thereofis to the best of my knowledge true and understand that any misrepresentation or failure todisclose any information may lead to my disqualification or termination of my employment contract, :Date:4446No. 37245 GOVERNMENT GAZETTE, 17 JANUARY 2014 This gazette is also available free online at