Private Security Industry

Regulatory Authority (SIRA)

THE DIRECTOR
PRIVATE SECURITY INDUSTRY Application for registration as a security service
REGULATORY AUTHORITY provider in terms of the Private Security Industry
PRIVATE BAG X817 Regulation Act 56 of 2001 (“the Act”)
PRETORIA
0001 APPLICATION FOR RENEWAL OF
INDIVIDUAL CERTIFICATE

APPLICATION
01 RENEWAL 02 REISSUE 03 UPGRADE 04 CHANGE OF ID/NAMES

/ 0 4 / 0 4 / 2 0 2 3 Application Date (dd/mm/yyyy)

PARTICULARS OF APPLICANT
South African Identification Number / Permit number / Asylum
7 1 0 5 1 1 0 7 6 0 0 8 9 papers

2 0 4 4 3 2 3 PSiRA Number

M b a t h a Surname

G u g u P r u d e n c e Full Names

PLEASE TICK

CLOSE
MALE FEMALE 03 UPGRADE 04
CORPORATION

PHYSICAL ADDRESS OF APPLICANT

E s t c o u r t

B 4 8 5 L o u g o m e s S e c t i o n

W e m b e s i

3 3 1 0 Postal Code

POSTAL ADDRESS (if different to Physical Address)

E s t c o u r t

W e m b e s i

3 3 1 0 Postal Code

TELEPHONE NUMBERS (Code/Number)

0 7 1 1 2 6 6 1 6 3 Business Fax Cellphone

ilalelihle@gmail.com
____________________________________________________ Email address

IS THE APPLICANT EMPLOYED? YES NO

CURRENT EMPLOYER: EMPLOYEE NUMBER:

Gugu Prudence Mbatha 7105110760089

I the undersigned, ______________________________________________________________________________________
Full name and identity number

Page 1 of 3 Pages
declares that the information furnished on this form is true and complete to the best of my knowledge. I agree that Private Security
Industry Regulatory Authority may summarily approve\rejects my application in case any of the information/record(s) furnished above
found to be incorrect or false and I will not make any correspondence in the matter whatsoever and I will abide by the decision of the
Private Security Industry regulatory Authority.

THUS DONE AND SIGNED at 04 on 04 23

Of 20____

SIGNATURE:

FOR OFFICE USE ONLY

1. Purpose of the visit collection of new certificate/ re issue/upgrade
2. Confirmation of registration with PSIRA YES/NO
3. Confirmation of Grades or any other course YES/NO
4. Confirmation of ID/ Permit/passport with DHA YES/NO
5. Update of the postal ad physical address YES/NO
6. Proof Old certificate/affidavit YES/NO
7. Total amount to be paid R40.00 certificate (1st renewal
with old certificates) and R20.00 (2nd renewal) and R60 card and re issue of certificate/card
is R90.00

I have confirmed the above to be correct

Name of PSIRA official-------------------------------- Signature--------------------------------------------

Date ------------------------------------------------------

Page 2 of 3 Pages
 Security Industry Regulatory Authority
Renewal of certificate Checklist - Individual
Name Gugu Prudence Mbatha

Date

REQUIREMENT

1. Duly completed application form (Renewal of individual certificate form)

Payment of prescribed amounts ( Certificate R40 First issue / R20 Second renewal /R90 Re issue , Card R60 First issue /
2.
R90 Re issue certificate )

3. Authenticated copy of first page of ID document/ Permanent/ Work permits/ Asylum papers

4. Original Psira certificate (affidavit if lost / misplaced)

Page 3 of 3 Pages