Elias Motsoaledi Local
Municipality
P.O. Box 48
Phone: (013) 262 3056/2643
Fax: (013) 262 5075/2886 Groblersdal
0470 [Link]
APPLICATION FORM FOR EMPLOYMENT: STAFF MEMBER POST(S)
TERMS AND CONDITIONS:
1. The purpose of this form is to assist the 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 Elias Motsoaledi Local Municipality to expedite recruitment and selection processes.
4. All information received will be treated with strictly 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 Elias Motsoaledi Local Municipality with the recruitment,
selection and appointment of staff member in terms of the Local Government: Municipal
Systems Act 32 of 2000.
A. DETAILS OF THE ADVERTISED POST (as reflected in the advert)
Advertised post applying for
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 you a South African Yes No
Citizen?
If no, what is your Nationality?
Work Permit Number (if any)
Physical Address: 2nd Grobler Avenue Groblersdal 0470. Postal Address: P O BOX 48 Groblersdal 0470
Do you hold any political office in a political party, whether Yes No
in a permanent, temporary or acting capacity? If yes,
provide information below.
Political party: Position: Expiry date:
Do you hold a professional membership with any Yes No
professional body? If yes, provide information below
Professional Body: Membership Number: Expiry Date:
C: CONTACT DETAILS:
Preferred language for
correspondence?
Telephone number during office hours
Preferred method for correspondence Post E-mail Fax
(Mark with an X)
Correspondence contact details (in
terms of above)
D. QUALIFICATIONS (Additional information may be provided on your CV)
Name of School / Technical College Highest Qualification Year Obtained:
Obtained:
Name of Institution Name of NQF Level Year Obtained
Qualification
Physical Address: 2nd Grobler Avenue Groblersdal 0470. Postal Address: P O BOX 48 Groblersdal 0470
E. WORK EXPERIENCE (Additional information may be provided on your CV)
Employer From To Reason for leaving
(starting with the Position Month Year Month Year
most recent)
If you were previously employed in Local Government, Yes No
indicate whether any condition exists that prevents
your re- employment:
If yes, provide the name of the
previous municipality:
F. DISCIPLINARY RECORD
Have you been dismissed for Yes No
misconduct on or after 5 July 2011?
If yes, Name of Municipality / Institution
Type of a Misconduct / Transgression
Date of Resignation / Disciplinary case
finalised
Award / sanction
Did you resign from your job on or after
5 July 2011 pending finalization of the Yes No
disciplinary proceedings? If yes,
provide details on a separate sheet
G. CRIMINAL RECORD
Were you convicted of a criminal
offence involving financial misconduct,
fraud or corruption on or after 5 July Yes No
2011? If yes, provide details on a
separate sheet.
If yes, type of criminal act
Date criminal case finalized
Outcome/ Judgment
Physical Address: 2nd Grobler Avenue Groblersdal 0470. Postal Address: P O BOX 48 Groblersdal 0470
H. REFERENCE
Name of Relationship Tel (Office Hours) Cell phone Email
Referee number
I. EMPLOYEE DECLARATION AND PRIVACY NOTICE
1. I declare that all the personal information furnished by me on this form is true and correct, and I
undertake to inform Elias Motsoaledi Local Municipality of any changes in my personal
information.
2. I, as a job applicant or an employee of the Municipality hereby consent that the Municipality may
collect, use, distribute, process my personal information for its business purposes, which may
include, but is not limited to,
2.1. internal administrative processes pertaining to my employment at the Municipality; and
2.2. conducting criminal, qualifications, credit, and reference checks.
3. I also consent that the Municipality may share my personal information with the Vetting Agencies,
External Auditors, South African Receiver of Revenue, Department of Employment and Labour,
Banks, service providers offering employees with various services as part of employment benefits,
councilors, relevant governance structures, relevant government institutions and legal entities
which may lawfully require such information for legal obligations.
4. I understand that in terms of the Protection of Personal Information Act (POPIA) and other laws of
the country, there are instances where my express consent is not necessary to permit the
processing of personal information, which may be related to investigations, litigation, compliance
with legislative requirements or when personal information is publicly available.
5. I will not hold the Municipality responsible for any improper or unauthorised use of personal
information that is beyond its reasonable control.
6. I confirm that I have read the notice and understand the contents.
Physical Address: 2nd Grobler Avenue Groblersdal 0470. Postal Address: P O BOX 48 Groblersdal 0470
J. 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
misrepresentation or failure to disclose any information may lead to my disqualification or
termination of my employment contract, if appointed.
Signature: Date:
Physical Address: 2nd Grobler Avenue Groblersdal 0470. Postal Address: P O BOX 48 Groblersdal 0470