Reference Number: __________________ Location Information: District: __________________ L/Municipality: __________________ Ward No: __________ Village __________________ Are you employed on any other EPWP projects/programmes with other organisations? Yes / No If yes, state the organizations If yes, state the organizations B. PERSONAL INFORMATION Surname First names Date of birth Identity number Race African White Coloured Indian Gender Female Male Do you have a disability? Yes No If Yes, State the type of Disability Are you a South African citizen? Yes No If no, what is your nationality? And do you have a valid work permit? Yes No Have you been convicted of a criminal offence or been dismissed from employment? Yes No Do you have any pending disciplinary case against you? Yes No If yes (Provide the details) Have you resigned from a recent job pending any disciplinary proceeding against you? Yes No If yes, Provide details Have you been discharged or retired from the services on grounds of ill-health or on condition that you cannot be re-employed? Yes No If yes, Provide details If your profession or occupation requires State or official registration, provide date and particulars of registration If yes, Provide details details in your ID or passport. 2 – Passport number in the case of non-South Africans. 3 – This information is required to enable the department to comply with the Employment Equity Act, 1998. 4 – This information will only be considered if it directly relates to the requirements of the position. 5 – Applicants with substantial qualifications or work experience must attach a CV. C. HOW DO WE CONTACT YOU Preferred language for correspondence? Telephone number during office hours C1. Household Information Alternative Contact Person Contact Number Number of people in the household Number of dependents in the household Number of children attending school D. LANGUAGE PROFICIENCY – state ‘good’, ‘fair’, or ‘poor’ Languages (specify) Speak Read Write E. QUALIFICATIONS5 Name of School/Technical College Highest qualification obtained Year obtained Tertiary education (complete for each qualification you obtained) Name of Institution Name of qualification Year obtained Current study (institution and qualification): F. WORK EXPERIENCE5 Employer (including current employer) Post held From To Reason for leaving MM YY MM YY Do you have a relationship with any existing Community Safety and Liaison official Yes No If yes, Provide the name of the official G. REFERENCES Name Relationship to you Tel. No. (office hours) DECLARATION I declare that all the information provided (including any attachments) is complete and correct to the best of my knowledge. I understand that any false information supplied could lead to my application being disqualified or my discharge if I am appointed: Signature: Date:

Jul 24, 2026