Company Letter Head and Logo with Contact Details

The Secretary
Mine Overseer’s Commission of Examiners
Private Bag X59
ARCADIA
0007

[Date]

DECLARATION OF SOBRIETY AND GOOD CONDUCT

[CANDIDATES NAME] AND [ID NUMBER]

Candidate’s Declaration

I, ...................................................., ID number .............................................., declare that I

am of sober habits and in good conduct. I further understand the responsibility that comes
with a legal appointment under the Mine Health and Safety Act, 1996 (Act No. 29 of 1996),
as amended.

__________________________ ____________________ __________________

[Job Title / Appointment] [Signature] [Date]
Mentor’s Declaration

I, ..................................................., ID number .............................................., declare that I

am the mentor of the applicant and can attest to his/her declaration.

__________________________ ____________________ __________________

[Job Title / Appointment] [Signature] [Date]
Manager’s Declaration

I declare that I know the above mentioned candidate and can attest to his/her sober habits
and good conduct.

__________________________ ___________________ __________________

[Name] [Signature] [Date]

_________________________
[Job Title]
Appointed under Section ........... / Regulation ...................

Manager’s Certificate Number: ............................