Z83(81/971431)
G.P.S81/971431
Republicof SouthAfrica
Effective01January2021
APPLICATIONFOREMPLOYMENT
A.THEADVERTISEDPOST(Allsectionsofthisformarecompulsory)
Position for which you are applying(as Departmentwherethepositionwasadvertised
advertised)
WHATISTHEPURPOSEOFTHISFORM
Toassistagovernmentdepartmentinselecti
ng a person for an advertised post. Reference number(asstatedinthe If you are offered the position, when can you
0609302515 start OR how much notice must you servewith
your current employer?
This formmay be usedtoidentify
candidatestobeinterviewed.Youneedtofilli
nallsections of this form completely,
accuratelyandlegibly.Thiswillhelptoprocessyo
ur
applicationfairly.
B. PERSONALINFORMATION1
WHOSHOULDCOMPLETETHISFORM Pali Onkemetse Koketso
Surname and Fullnames
Onlypersonswishingtoapplyforanadvertise
dpositioninagovernmentdepartment. Identity 0 3 0 4 2 05 7 1 5 0 8 5
Date of Number
DD/MM/YY
Birth Passport2
ADDITIONALINFORMATION number
Race3 African White Coloured Indian Other
Thisformrequiresbasicinformation.Candid Gender3 Female Male✓
ateswhoareselectedforinterviewswill be
requested to furnish additional Do you have a disability? Yes No✓
certifiedinformation that may be required to
make afinalselection. Are you a South African citizen? Yes✓ No
If no,what is your nationality? South african
SPECIALNOTES
Do you have a valid work permit?(only if non-SouthAfrican) Yes No✓
Have you been convicted or found guilty of a criminal offence Yes No✓
1– (including an admission of guilt)? 5
Allinformationwillbetreatedwiththestrictest Ifyes(provide the details)
confidentialityandwillnot bedisclosedor
Yes No✓
usedfor any other purposethanto assess the Do you have any pending crimina lcase against you?
suitability of a person, except insofar as it If yes, (provide the details)5
mayberequiredandpermittedbylaw. Your
personal details must Have you ever been dismissed for misconduct from the Public Yes No✓
correspondwiththedetailsinyourIDorpasspor Service?4
2–Passportnumberinthecaseofnon-
t. If yes (provide the details)6
SouthAfricans.
Yes No✓
Do you have any pending disciplinary case against you?
3 – This information is requiredtoenable If yes, (provide the details)
thedepartment to comply withthe
ohEmploymentEquity Act, 1998. Have you resigned froma recent job pending any disciplinary Yes No✓
proceeding against you? 4
4 – Ifyes,(please note that the provisions of the PublicService Act
Thisinformationwillonlybetakenintoaccoun shall apply).
tifitdirectlyrelatestotherequirementsofthep
Have you been discharged or retired from the Public Service Yes No✓
osition.
on grounds of Ill-health or on condition that your cannot be re-
employed?4
5- The Executive Authority shall consider
Are you conducting business with the State or are you a Yes No✓
thecriminal record (s) against the nature of
Director of a Public or Private company conducting business
thejobfunctions in
with the State?6If yes, (provide the details)6
linewithinternalinformationsecurityand
disciplinary code.
6-
Theapplicantmaysubmitadditionalinfor Yes✓ No
In the event that you are employed in the Public Service, will
mationseparatelywherethespaceprovid you immediately relinquish such business interests?
edisnotsufficient.
7- Private PublicSector
Please specify the total number of years of experience you have Sector
Departmentsmustacceptcertifieddocu
ments thataccompany 01
theapplication(s)withcertificationthatisu If your profession or occupation requires official registration, Date Reg.No
pto6 months, unlessthe advert provide date and particulars of registration
prescribesa longer period. None
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Z83(81/971431)
8- C. CONTACTDETAILSANDMEDIUMOFCOMMUNICATIONS
Eachapplicationforemploymentformmustb
e dulysignedand initialedbytheapplicant. Preferredlanguageforcorrespondence
Failure to sign thisform may
leadtodisqualificationoftheapplicationdurin
Method for
gthe selection process. Post E-mail✓ Fax Telephone
correspondence
Contactdetails(in terms [email protected]
of the above)
D.SOUTHAFRICANOFFICIALLANGUAGEPROFICIENCY–state‘good’,‘fair’,or‘poor’
Languaes(specify)
English Sepedi Xitsonga Isizulu Setswana
Speak Good Good Good Good Good
Write or read Good Good Good Good Good
E.FORMALQUALIFICATION7(fromhighesttothelowest)
NameofSchool/TechnicalCollege Name of qualification obtained Year obtained
Senthibele senior secondary School National Senior Certificate 2022
Current study (institution and qualification):
F.WORKEXPERIENCE(Also attach a detailedCV)6
Employer(including current Postheld From To Reason for leaving
employer)
MM YY MM YY
Khensane Duma Caretaker 01 2023 12 2023 Contract ended
If you were previously employed iin the Public Service,is there any condition that prevents your re-
Yes No√✓
appointment
If yes,Provide then name of the previous employing department and indicate the
nature of the condition.
G.REFERENCES
Name Relationship to you Tel.No.(office hours)
Grace and wisdom Supervisor 0609302515
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Z83(81/971431)
DECLARATION
I declare that all the information provided(including any attachments)is complete and correct to the best of my knowledge.Iunderstand
that any false information provided will result in my application being disqualified or disciplinary action taken against me if iam appointed:
Signature:O.pali the Date:28 August 2024
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