Document
240-68074709 Rev 6
Information Confirmation Identifier
Template Effective Date October 2021
Review Date October 2024
**PLEASE COMPLETE, PRINT, SIGN AND BRING THE DOCUMENT WITH YOU TO THE INTERVIEW **
POSITION: GRADE:
DIVISION: BUSINESS UNIT:
REFERENCE NO.: POSITION LOCATION:
CANDIDATE NAME:
DATE:
EXTERNAL CANDIDATES
Not Permanently Employed By Eskom: (Mark appropriate box with a X)
Fixed Term Employee Temporary Employment Service Employee
Part-time Employee Temporary Employment (Labour Broker))
Independent Contractor (Third Party Contractor)
Current/Last
Company:
Current/Last
Position:
Current TCTC Salary: Benefits:
Notice Period:
Have you previously worked for
Eskom (Temporary or Yes No If Yes, Unique No.:
Permanently)?
Reason for leaving Eskom:
Are you currently pursuing other vacancies in Eskom? Yes No
If yes, please provide the Job Title, Division and Grade:
Reason for considering leaving current position?
ESKOM EMPLOYEES
Permanently Employed By Eskom or Subsidiary of Eskom: (Mark appropriate box with a X)
Eskom Eskom Rotek Industry (ERI)
Unique Number:
Current Position: Position Grading:
Current Division:
Controlled Disclosure
When downloaded from the document management system, this document is uncontrolled and the responsibility rests with the user to
ensure it is in line with the authorized version on the system. No part of this document may be reproduced in any manner or form by third
parties without the written consent of Eskom Holdings SOC Ltd, © copyright Eskom Holdings SOC Ltd, Reg No 2002/015527/30
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File name: 916188766.docx
Template ID: 240-43921804 (Rev 7) Header and Footer portrait template
Document
240-68074709 Rev 6
Information Confirmation Identifier
Template Effective Date October 2021
Review Date October 2024
Manager aware of
Current Manager: Yes No
application?
Recruiter:
Are you currently pursuing other vacancies in Eskom? Yes No
If yes, please provide the Job Title, Division and Grade:
Reason for considering leaving current position?
G E N E R A L (To be Completed by All)
Where are you currently
based?
Willingness to relocate: Yes No N/A Preferences:
Drivers Licence: Yes No Code:
Highest Completed Qualification:
Qualification relevant to
Institution:
the position:
Year completed:
Do you have proof of completed qualifications? Yes No Handed-in Yes No
Current Studies: Qualification :
Institution:
Year to Complete:
Do you have a financial Yes No If yes provide details:
obligation with your
current employer?
Professional Yes No Institution:
Registration/s:
Type / Level of Registration
Current Allowances:
Declaration of Interest: Do you have anything to declare in terms of the following? (To be Completed by All)
I Perform private work for Accepted a directorship in a
Yes No Yes No
additional remuneration. company.
Stand for election or
appointment to a statutory Obtained membership of a closed
body or any other body, which Yes No corporation or share in a Yes No
may interfere with Eskom partnership or a joint venture?
duties.
Controlled Disclosure
When downloaded from the document management system, this document is uncontrolled and the responsibility rests with the user to
ensure it is in line with the authorized version on the system. No part of this document may be reproduced in any manner or form by third
parties without the written consent of Eskom Holdings SOC Ltd, © copyright Eskom Holdings SOC Ltd, Reg No 2002/015527/30
Page 2 of 3
File name: 916188766.docx
Template ID: 240-43921804 (Rev 7) Header and Footer portrait template
Document
240-68074709 Rev 6
Information Confirmation Identifier
Template Effective Date October 2021
Review Date October 2024
Either myself or any of my
Do you have any family members
close relatives have direct or Yes No Yes No
working for Eskom?
indirect interest in Eskom
Please provide us with more
details regarding any of the
listed or any possible conflict
of interest that could arise
should you be employed by
Eskom or in this Business
Units.
PLEASE NOTE THAT THE ABOVE DECLARATION DOES NOT NECESSARILY DISQUALIFY YOUR
APPLICATION. HOWEVER, PLEASE INCLUDE ALL THE INFORMATION NECESSARY FOR ESKOM TO MAKE
AN INFORMED DECISION.
PLEASE REMEMBER TO BRING THE FOLLOWING DOCUMENTS WITH YOU TO THE INTERVIEW:
Certified copies of the following documents: Qualifications, ID, Driver’s Licence and Professional Registration (if
applicable).
Please also bring a completed and signed copy of your Application Form (GA20 Form) and MIE Indemnity form (2
pages).
As part of our Criminal Record Verification process, please ensure that you have your fingerprints taken at your
nearest police station on a 91 (A) Form and bring the original form with you to the interview (Unless otherwise
instructed by the Recruitment Coordinator).
Read carefully before signing: I certify that the information on this form is true and accurate to the best of my
knowledge. I understand that false or incomplete information may constitute grounds for dismissal and an
investigation may be made of my background and used relative to my employment status. I also authorize my
former employers and any other persons or organizations to provide any information that they may have about
me and I release all concerned from any liability in connection herewith.
Applicant Signature Date
Controlled Disclosure
When downloaded from the document management system, this document is uncontrolled and the responsibility rests with the user to
ensure it is in line with the authorized version on the system. No part of this document may be reproduced in any manner or form by third
parties without the written consent of Eskom Holdings SOC Ltd, © copyright Eskom Holdings SOC Ltd, Reg No 2002/015527/30
Page 3 of 3
File name: 916188766.docx
Template ID: 240-43921804 (Rev 7) Header and Footer portrait template
