MASSMART INTERNAL APPLICATION FORM

2023

Date: ______________________

Kindly complete in BLOCK letters in your own handwriting, alternatively submit as PDF with relevant electronic
signatories. Selecting options with a cross [X] in the appropriate block.

 Applications won’t be processed if not signed by the People Partner

PERSONAL DETAILS
Employee Number
Surname
First Names
Date of Birth Title Mr Mrs Miss Ms Other

Male Female Other

Gender

Race African Coloured White Indian

Nationality
Are you living with Please specify if yes and indicate if reasonable
Yes No
a Disability? accommodation is required:
City of Residence
Mobile No.
Transport Own Public Lift

Language
Proficiency

POSITION APPLIED FOR

Position Title
Massmart Massmart Massmart
Division
Corporate Retail Wholesale
Location | Branch (Sandton / Sunninghill /Store location )

EDUCATIONAL QUALIFICATIONS
Highest School
Qualification

Other
Qualification
Details

Current Study
Details

Please note that all appointments will be made in line with Massmart’s Employment Equity Plan.
CURRENT EMPLOYMENT DETAILS
Current Position
Time Frame /
Start Date
Massmart Massmart Massmart
Division
Corporate Retail Wholesale
Location |
(e.g. Sandton / Sunninghill / Store Location)
Branch
Employment Contracted to Massmart
Permanent Contract Casual
Status through external vendor

Line Manager’s Name and Surname:

Details Designation:

EMPLOYMENT HISTORY
Massmart Group
Position Company | Location Time Frame

Other Employment
Position Company | Location Time Frame
MASSMART INTERNAL APPLICATION FORM

2023

GENERAL
Have been promoted in the last 12 months? If so please provide detail of promotion.

Are you willing and able to work some Saturdays and Sundays? If not, please furnish reasons

Indicate your reasons for applying for this position.

In what way do you believe that you are suitable for the advertised position?

What relevant experience, knowledge, skills and abilities do you have to support your application?

Detail any previous / current training courses completed, and how they relate to the advertised position.

Please note that all appointments will be made in line with Massmart’s Employment Equity Plan.
FOR COMPLETION BY YOUR DIRECT LINE MANAGER

Please complete the sections below as thoroughly as possible.

Based on the information provided herein, please give feedback to the applicant on your comments.

Regardless of whether you do / do not support the application, please forward to the Human Resources Department.
In cases where you do not support the application, please comment accordingly below.

Are you in support of the application? If not, please specify reasons

Comment on the applicants’ past work performance record, highlighting both positive and negative incidents.

Comment on the applicants’ future career development potential

List 5 of the applicants’ areas of strength and development

Areas of strength Areas for Development

Required Signatures

People Partner Name

Date:
People Partner Signature

Applicant Name

Date:
Applicant Signature
MASSMART INTERNAL APPLICATION FORM

2023

Please note that all appointments will be made in line with Massmart’s Employment Equity Plan.
Anti-Corruption Screening Form
(to be completed by in-scope applicants as defined in the Anti-Corruption HR Screening Plan, v2.2020)
Notice to Applicants: The information collected herein is part of the application process, is being collected to determine if
you have any conflicts of interest that may present a corruption risk or an appearance of improper influence for the
position that you are applying for, and the Company reserves the right to ask for additional information beyond what is
asked in this application. Furthermore, by completing this application, the applicant agrees that if subsequent
developments cause the information reported herein to be no longer accurate or complete, the applicant will immediately
notify the Company regarding a change in circumstances. By providing this information, the applicant certifies that the
statements and information contained in this submittal are true, accurate, and complete. Any misrepresentation or
concealment of information may result in the employment termination in accordance with market-specific policies.

The information collected on this form is used for recruiting and employment purposes.

1. Have you been employed by a Government Entity within the last two years, or are you
currently employed by a Government Entity, or do you anticipate holding a government
position/title within the next 12 months?
A Government Entity is any government department, agency, ministry, instrumentality, entity, political
party, political campaign, state-owned enterprise, public international organization, recognized traditional
or tribal council, or recognized traditional or royal family. In the case of political party candidacy or
position, please state the office for which you are running or hold/held (ex. mayor), but do not identify the
political party affiliation. Examples of Government Entities include but are not limited to the Mayor’s
Office, a Police Station, a Fire Department, a Building Inspection Office, a City Clerk’s Office, a
government owned utility provider, etc.
YES NO

If “YES”, provide the information regarding past/current/future government employment below

(attach list on a separate page, as needed):

For Past Government Positions (Last Two Years)

Please identify the Government Entity that employed you:

____________________________

Please identify the position/title you held: ___________________________________________

Please identify the dates that you were employed: ____________________________________

Please identify the city where the Government Entity is located: __________________________

For Current Government Positions

Please identify the Government Entity that employs you: ______________________________

Please identify the position/title you hold: ___________________________________________

Please identify the city where the Government Entity is located: __________________________

For Future Government Positions (Future 12 Months) mark “N/A” if future employment is not known

Please identify the Government Entity that you anticipate holding a position/title with
within the next twelve months: ________________________________________________

Please identify the position/title that you anticipate holding: ____________________________

Please identify the city where the Government Entity is located: _________________________

2. Do you have any family members who are Government Officials or are employed by a
Government Entity?

Family members include parents, children, siblings, spouses, and spousal equivalents. A Government
Official is: (i) any officer or employee of a Government Entity; (ii) any person acting in an official
capacity for or on behalf of a Government Entity; or (iii) any candidate for a public office position or
any person acting in an official capacity for or on behalf of the candidate. In the case of political party
MASSMART INTERNAL APPLICATION FORM

2023

Anti-Corruption Screening Form

(to be completed by in-scope applicants as defined in the Anti-Corruption HR Screening Plan, v2.2020)
Notice to Applicants: The information collected herein is part of the application process, is being collected to determine if
you have any conflicts of interest that may present a corruption risk or an appearance of improper influence for the
position that you are applying for, and the Company reserves the right to ask for additional information beyond what is
asked in this application. Furthermore, by completing this application, the applicant agrees that if subsequent
developments cause the information reported herein to be no longer accurate or complete, the applicant will immediately
notify the Company regarding a change in circumstances. By providing this information, the applicant certifies that the
statements and information contained in this submittal are true, accurate, and complete. Any misrepresentation or
concealment of information may result in the employment termination in accordance with market-specific policies.

The information collected on this form is used for recruiting and employment purposes.
candidacy or position, please state the office for which you are running or hold/held (ex. mayor), but
do not identify the political party affiliation. Examples of individuals who are Government Officials or
are employed by Government Entities include but are not limited to mayors, city council members,
police officers, fire inspectors, building inspectors, government tax collectors, city clerks, government
inspectors, or any individual who receives his or her paycheck from a Government Entity.

YES NO

If “YES”, are these family members in a position that interacts or could interact with the
Company?

YES NO

If “YES”, provide the information regarding your family member(s) below (attach list on a
separate page, as needed):

Family Member
Position/Title Held by Family Member: ____________________________________________

Government Entity that Family Member is Employed By: ______________________________

Please identify your relation to the Family Member above: _____________________________

Applicant Name: ________________________________________________

printed

Signature: _____________________________________________________

must be signed in ink

Date: ________________________________________________

Please note that all appointments will be made in line with Massmart’s Employment Equity Plan.
 DECLARATION

I _______________________________ declare that the information given in this document is accurate. I understand
and accept that any false declaration will automatically and immediately render my contract of service invalid. I
furthermore permit the company to undertake criminal, behaviour and background checks which it may consider
appropriate including contacting references, previous employers and institutions of learning.

Furthermore, I declare that I do not currently know of any medical condition that would render me unable to perform
the inherent requirements of the job.

Consent:

Please take note that by responding to this application and providing your personal information, you confirm your
express and informed consent for Massmart Holdings Limited Pty(Ltd) and all its subsidiaries and all affiliated
companies (“Massmart”), to process your personal information in order for Massmart to consider your application for
this position.

All Personal Information which you provide to the Company will be used and/or retained only for the purposes for
which it is collected, where after it will be permanently destroyed. Your information is only retained if it is required by
law or where you have given consent to us to retain such information for an extended period. To read more about our
privacy policy and how we process your information, please visit https://www.massmart.co.za/privacy-policy/

I agree and consent

Signature of applicant

Date: