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Employment Application Form

Position applied for:en

Personal Details

First Name: Initials:V

Surname: Name Known as:Stevenson

Identity

number6311290250088

Gender:

Do you have a disability as defined by the Department of Labour? If yes, please specify:

Date of birth:

Are you a South African Citizen?

If no, do you have a work permit to work in South Africa? If yes, please provide a certified copy of your work permit attached to this application form. Contact phone numbers: Residential Address: Postal Address: Cell

Landline

Other

African

Coloured

Asian

White

Male

Female

Y

N

Y

N

Y

N

Race:

Page 2 of 6 pages

Job information

Part time:

How did you hear about this position?

Qualifications

Highest qualification:

Institution:

Date qualified:

Other relevant qualifications:

Institution:

Date qualified:

Previous Employment

Employer: Job Title:

Start date: End date:

End salary and benefits:

Reason for leaving:

Present Employment

Employer: Job Title:

Start date:

End salary and benefits:

Reason for wanting to leave:

Y

N

Y

N

Full time:

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General

Have you previously:

Applied to work at a Life Healthcare hospital or business unit? Worked at a Life Healthcare Hospital or business unit? If yes, which hospital or business unit and what was your position title? Do you have any relatives employed by Life Healthcare? If yes, please give details:

Do you have any physical health limitations that will prevent you from performing the job that you are applying for? If yes, please give details:

Where applicable, and in the execution of your normal duties, you may be exposed to certain health risks. The following are examples of such health risks:

Manual handling of objects or patients (i.e. muscular-skeletal problems, back-, neck- or shoulder pain)

Latex (i.e. dermatitis, asthma)

Radiation (i.e. pre-malignant or malignant condition)

Chemicals (i.e. dermatitis, asthma, chronic bronchitis) If you have any of the above or another condition that may be worsened and may have an impact on your appointment, please disclose such information below: Y

N

Y

N

Y

N

Y

N

Page 4 of 6 pages

Registration to work

Do you require a licence or registration to perform the work you are applying for?

If yes, please complete the following:

Registration type: Registration number:

Registration Body: Registration date:

Renewal date: Expiry date:

Country issued:

References

1. Company:

Position:

Contact Person name:

Position of contact person:

Contact phone number:

2. Company:

Position:

Contact Person name:

Position of contact person:

Contact phone number:

Y

N

Page 5 of 6 pages

3. Company:

Position:

Contact Person name:

Position of contact person:

Contact phone number:

May Life Healthcare contact the references listed above? Consent & Declaration

It is in both your and the Company’s best interest to perform integrity assessments prior to employment. An integrity assessment involves compiling a comprehensive background check relevant to the job that will be performed, for example all employees working in the finance sector must have their references and qualifications verified as well as a credit and criminal record check. One or more of the following methods are used:

Reference check with referees as supplied

Qualification check

SANC check (if applicable)

Credit and/or criminal check

I hereby voluntarily provide consent for an integrity assessment to be carried out on me. I accept that the integrity assessment is part of the pre-employment selection process and that Life Healthcare is under no obligation to make use of my services. Please note that the information gathered will be dealt with on a strictly confidential and discreet basis. Is there any other information, which may have a bearing on your suitability for the position? If yes, please detail (nature, date)

Date: Place: Signature: Y

N

Y

N

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Declaration:

I hereby declare that all particulars and answers in this application form are true and no material fact has been withheld. I agree that this application and declaration shall be the basis of any contract between the Company and me, that the withholding of any material information or failure to answer the questions correctly will constitute a breach of a condition of my employment (if I am successful in my application) for which I may be dismissed. Signature Date

Recruiting Line Manager Date

Contact this candidate