[Insert onto official letterhead in colour.

For the latest version of this template and

guidance see https://www.michalsons.com/blog/permit-to-perform-essential-service-
template-and-guidance/42542]

Form 2

Permit to perform essential services

We issue this form in accordance with Regulations 16(2)(b) and 28(4) of the COVID-
19 Regulations issued in terms of section 27(2) of the Disaster Management Act on
18 March 2020 (as amended on 29 April 2020 in Government Gazette No. 480). This
form corresponds substantially with Annexure A to the COVID-19 Regulations.

Please note: The person to whom this permit is issued must at all times carry a
form of identification (any form of ID with a photo and identity number) and present
it together with this permit. If they don’t, they will have to return to their place of
residence during Alert Level 4.

I,
Surname
Full names
Identity number
Cell number
Work number
Home number
Email address
Role (for example, head,
manager or role of
delegated person)
Name of my institution
Physical address of my
institution
Website of my institution
(optional)

confirm that my institution performs an essential service as described in Annexure D

of the COVID-19 Regulations in that it falls into category (specify the
number between 1 and 35 of the categories listed in Annexure D).

I hereby certify and designate that:

Surname
Full Names
Identity number
Place of residence of
employee

Template drafted by Michalsons – www.michalsons.com

Free for anyone to use
  is a staff member of my institution (or a supplier to it) and essential to
performing the essential services; and
 needs to perform their services at the physical address of my institution.

I authorise them to travel between the physical address of my institution and their
home for the period of the lockdown.

Signed at , on this the day of 2020.

___________________________

Signature of the Head of the Institution (or delegated person)

(I confirm that I am duly authorised to sign this form in accordance with Regulations
16(2)(b) and 28(4) in that I am either the head or the head has authorised me to
sign)

(This form does not need to be signed before a Commissioner of Oaths)

Official stamp of the

Institution

Template drafted by Michalsons – www.michalsons.com

Free for anyone to use