CONFIDENTIAL
APPLICATION FORM FOR EMPLOYMENT
N.B. PLEASE COMPLETE ALL SECTIONS IN BLOCK CAPITALS USING BLACK INK
TERMS AND CONDITIONS
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.
3. Candidates shortlisted for interviews may be requested to furnish additional information
that will assist municipalities to expedite recruitment and selection processes.
4. All information received will be treated with strict confidentiality and will 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
senior managers 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 for
Position Code
Reference number
Name of Municipality
Notice service period
B. PERSONAL DETAILS
Surname
First Names
ID or Passport Number
Race
African
Coloured
Indian
White
Gender
Female
Male
Do you have a disability?
Yes
No
If yes, elaborate
Are a South African citizen?
Yes
No
If no, what is your
Nationality?
Work Permit Number (if any)
Do you hold any political office in a political party, whether in a permanent, temporary or acting
capacity? If yes, provide information below.
No
Political Party:
Position:
Expiry date:
Do you hold a professional membership with any professional body? If yes, provide
information below
Yes
No
Professional Body:
Membership Number:
Expiry date:
C. CONTACT DETAILS
Preferred language for
correspondence?
Telephone number during office hours
Preferred method for correspondence (Mark
with an X)
Post
E-mail
Fax
Correspondence contact details (in terms of
above)
D. QUALIFICATIONS (Additional information may be provided on your CV)
itional information may be Eprovided oi :iLJI n
-
C A
Name of School / Technical College
Highest Qualification Obtained
Year Obtained
Name of Institution
Name of Qualification
NQF Level
Year Obtained
E. WORK EXPERIENCE (Additional information may be provided on your CV)
Additional information may be provided on your CV)
Employer (starting with the most
recent)
Position
From
To
Reason for leaving
MM
YY
MM
YY
If you were previously employed in Local Government, indicate whether any
condition exists that prevents your re-employment:
Yes
No
If yes, provide the name of the previous
employing municipality:
F. DISCIPLINARY RECORD
Have you been dismissed for misconduct on or after 5 July 2011?
Yes
No
If yes, name of Municipality/ institution:
Type of Misconduct/ Transgression
Date of Resignation/ Disciplinary case finalized
Award/ sanction
Did you resign from your job on or after 5 July 2011 pending finalisation
of the disciplinary proceedings? If yes, provide details on a separate
sheet.
Yes
No
G. CRIMINAL RECORD
Were you convicted of a criminal offence involving financial misconduct,
fraud or corruption on or after 5 July 2011? If yes, provide details on a
separate sheet.
Yes
No
If yes, type of criminal act
Date criminal case finalized
Outcome/ Judgment
H. REFERENCE
Name of Referee
Relationship
Tel. (office hours)
Cellphone Number
Email
I. 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 misrepresentations or failure to
disclose any information may lead to my disqualification or termination of my employment contract, if
appointed.
Signature:
Date:
