Empower Financial Services (Pt y) Ltd

H Group Building
13 Challenger Avenue | International Business Gateway Midrand|
1685
Johannesburg | South Africa

INDEMNITY FORM

CANDIDATE NAME: ____________________________________

CANDIDATE ID NUMBER: _______________________________

1. I am participating in training with Empower Fin (Pty) Ltd voluntarily and at my own risk outside the Company’s
premises which will be conducted through the Company for a period of up to six days.

2. I am aware that risks exist and may arise during this period (including, but not limited to, the hazards of traveling
by bus, coach, tram, train, vehicle, water transport or other means in isolated or mountainous terrain, away from
medical facilities and subject to the forces of nature) by which death, injury or illness to me or damage or loss to
my property may occur.

3. I accept and assume all the risks of participating in the training. Further, I (and my heirs assigns, executors and/or
administrators) fully and finally release Empower Fin (Pty) Ltd, its servants, employees, agents and contractors
from any and/or all responsibility or liability for any loss of or damage to any of my property, or any injury or
death to me arising in any manner whatsoever (including by way of negligence of any other person or entity) out
of my participation in the training.

4. I have read and accept the term and conditions of participating in training.

5. I acknowledge that I have accepted the risk stated above and given the release stated above of my own free will
and I have not relied upon any verbal, written or visual representations or statements made by Empower Fin (Pty)
Ltd and/or its servants, employees, agents and contractors.

Signature of Candidate: _________________________ Date: ________________________

Reg No. 2012/098185/07 | FSP 44565 | VAT Reg No.4390261123

Tel: +27(10) 900 3212 | Fax: +27 (86) 616 9334 | Email: info@empowerfs.co.za