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Copyright Lust updated 2019

(A)Company Details ("The Company") lo be completed by Company Agent -PLEASE PRINT

Personal Credential Verification

Permission and lndemnity Declaration

Company Name: Email:

Branch Name: Phone:

(B) Checks Required

ldentity Checks Academic Qualifications Enatis Checks

O Yimi O Matric Pre 92 Umalusi D Driver's Licence
0 1D Verification U Matric Post 92 Umalusi O Professional Driving Permit
0 Citizenship Verification 0 South Africa Qualification | Vehicle Information
U SA Work Permit O N-Levels Title Holder Information
0 Asylum Permit 0 Global Qualification
D Bank Account Verification

Credit Checks Employment Checks Criminal Checks

0 Transunion Credit 0 Fit &Proper O Fraud Listing

U Compuscan Credit O FAIS Comprehensive O Criminal Record Check
) Experian Credit ) Professional Associations
O XDs Credit ) Social Media Check

Doyou have any previous Charges

O Yes M No If yes, please list:

Bureau IDVerification
Agent Name:
NOTE:

Required: Please select reason code from the list below

Bureau Comprehensive
Bureau Notices

**1. Employment in aposition that requires trust and honesty and entails the handling of cash or finances
2. Verifying educationalqualifications and employment
3. Fraud detection and fraud prevention services

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CjyrghtLast updated 2019

(C)Personal Information

Surname: Maiden Name:

Full First Names:

Primary ID No:
NokuuA Date of Birth: ( JuE 996

ql6068O6hOolo
2nd ID / Passport:

Permit Number:

Res. Address: GIEIE STREET Code:

CE2 VAoER BIpARk

(D) Qualification Information To be completed byCandidate - PLEASE PRINT

(1) (2) (3)

Qualification: ATRIC B.EuATo B.ED Horts

Institution /School:

Province / Address:

Date Obtained:

Student No:
2014 2014
Certificate No:

Exam No:

(E) Bank Account Verification To be completed by Candidate - PLEASE PRINT

Intitals

Surname

Bank Name CAeTEC

Accoutn Number
|4 q3247S|2
Account Type
SAvitGGs
Branch Code
4700(0
 Contributing
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(F) Indemnity Declaration lo becompleted tby Canddhte - GIGN and DATE

Ihereby authouze the Company's duly authorized verilication aqent, Dots Africa. to forward any peronal ifortmation . V.lil
As any infonation that thave provided in support of my application to veihcation iofonalion uppliors acting ou begh.alf of
Dots360 (ncuding but not linited to the South Afican Police Services/ldeco, the Govennept of the fSA, and any
educational, traning. credit bureau and fraud prevention organizations) for lhe pupose of vermying my personal crederilisl
aDd tecOLds. Aulhorized ciedential verificalion lypes include, bul ae nol limited to. educalional qualificalio0:%, profcsSional

membership. employnment history. enployment references, consumer credit, criminal record, driv:rs' license and fraud

prevention checks. Iautthorize Dots360's verihcation information suppliers to furnish infomation regarding my credentials.
whether claimed or not, to Dots360 and the Company. Iunconditionally indernnify Dots360 and its verificatiow infortnatron
suppliers against any liability that may result from furnishing information in this regard. Iunderstand that it is a condition of
Dots360's verifcation infor nationsuppliers tihat this information is furnished by then solely for the purposes of ny proposed
/ continIation of empioyment via the offices of the Company and that any inforination that is furnished to the Company and
Dots360 will be disclosed to me before a decision is nade on my continued employment or application for employment.
Furthermore, Iauthorize Dots360 to host my fingerprints and, upon request and with ny consent, to rclease crinina! results to
other organisations.

Personai Information" shall have the neaningascribed to it in Chapter 1 of POPI and includes, but is not limited to a name.
aiiresS. email addresS, telephone or fax number. crininal history and education or other personal credentiais provided, or

which is coilected from the candidate or other third parties. before and/or during the background screening process and/or
thereafter:

iunderstand that verifcation requests form part of the background screening process and Data obtained from the FSCA serve
only for the purpOse to determine the fitness and propriety as envisaged in the FAIS Act.

iacknowiedqe that any Personal infornation supplied to the Copay is provided voluntariiy and that the Conpany may not
be able to comply with its obligations if the correct Personal infotmation is not supplied to tihe Company.

Personat Information may be shared by the Verification tnfOMation SupplierS with Dots360 arnd be further stored and shared
by Dots360 witth the Company

Personal Infomation may be stored for a reasonable period by the Company. Dots360 and/or the Verifcation Infomation
Supplier s, and Itake note that if the Responsilble Party hasutilised the Personal nfomation contrary to the Privacyand Data
Protection Conditions, Imnay first resolve arny concerns with hat Responsible Parly. If Tam not satished witly such process. I
have the right to lodge a complaint with the Informaion Regulalor

Acopy of Personal information kept by the Responsible Parties willbe furnished to rme upon request in terms of the provisions
of POP! or the NCA and Iunderstand that I may dispute any informalion in the recotd provided.

Iagree toindemnify the Responsihle Parties, andVeification Infornation Supplies, acting in good faith in taking allteasonable
steps to process ny Personal Infomation lawfully, aganst any iability that may lesult fiom the pr0CPssing of my Pet Sonal
Information. Provided, howEVeL tthat this indemnity shall be of no forCe and effect in the event that my Per sonal lfomation
Is dealt witlh begligentty or fot any purpose for winchit was not intended in terns hereof
 Contributing
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(G) SocialMedia Indemnity Declaration lo be completod by CanddaleSIGN and DATE

Iherehy authotise the above oDpay / the coMpay' duly authorISCda0ent, to nlake myI e . suamr indothher supphed
detals avalable fo euse of Dots Africa, in Oder to cOnduct solCi backurounl coeDg Ifurthe LOHCnt thst |

Iave willingly suppled thedetails tor allsocalmedi ccouts which arc hold by tue

In conductina the search/s refered to above, Icon/ hal |have/have nol beon focot/ coctcedinto si(ninarnd ssupplyinG
the above infomation.

Iconscnt to the further procossing of my personal infomation insofar as this is in aCCOrdanCe and cotnpatible vzith the purpos%e
for which the information has been collected. alternativelv insofar as this infornation has deliberately been made public by me

and/o is derived from apublic record.

Iunderstand that this indennity is conditional for the ethical social media backaround screning practices and, in that
a. The infornmation is furnished solely for the purpose of my
proposed employment
b. any information furnished to the conpany/the companv's duly authorised aqent, will be disciosed to me for cominent and i

understand and accept that the purpose of the report is to proyide one factor, among a range of factors. for consideration by
the company/the company's duly authorised anent as to my application and/or suitability for employment/ application: and

c. the conipany / company's duly authorised agent is responsible for veritying the accuracy. in the respect, of the information
furnished by the South African Police ServiCe.

d. The record of personal information will be stored securely and wil not be retained any longer than is necessary for achieving
the legitimate purp0se for which it will be collected and processed in terns hereof.

2023
Candidate Signature DD MM CCY Y

As the enquiring Agent of the Company. and in the case that this fon instructs Dots360 to piovide consumer credit
information, Ihereby state that Iunderstand the provisions of the National Credit Act (34 of 2005). section 70(2)a). and the
Rogulations made in terms of the Act, section 18(4) and (5).

AGENT SIGNATURE DD MM CCY Y

All siqnatorios to this document agree that Dots360 will NOT Ibe held iable for the content, factual corectnks ot AccUacy of
any Suppher Data supplied to Dots 360 for the Company by Dots360's suppieS. he Company and the Candidato hereby
indemnifies oid hold Dots360 ham1less against ay loss aisiDg rom neqlect or lamaqe i) procUiDOComEntcating or

failing to communicate infoImation to fhe Company