Personal Credential Disclosure Form

(A) COMPANY DETAILS

(The Company)

To be completed by Company Agent PLEASE PRINT

Affinity Staffing Solutions

Company Name:
Branch Name:

Email:
Phone:

Renate Swarts

Agent Name:

Fax:

renate.affinity@gmail.com
+27 61 103 4043
086 274 1233

(B) PERSONAL INFORMATION

Surname:

Dirker

Full First Names:

Hendrik

Maiden Name:

Date of Birth:

13/05/1980

8005135168087

Primary ID No:
nd

2 ID / Passport:

1115 Chateau Ave., Allensnek, Roodepoort

Res. Address:

Code:

To be completed by the individual PLEASE PRINT

(C) QUALIFICATION INFORMATION

(1)

(2)

Qualification:

Boilermaking Certificate

Institution/School:
City / Address:

Merseta
Olifantsfontein

Date Obtained:

2003

1724
(3)

PMP

NDip. Mech. Eng.

VUT & UNISA

PMI

In Progress

In Progress

Student No:
Certificate No:

17/5168/03556

Exam No:

To be completed by Candidate SIGN and DATE

(D) INDEMNITY DECLARATION

I hereby authorize the Companys duly authorized verification agent, Managed Integrity Evaluation (Pty) Ltd (MIE), to forward any personal information
as well as any information that I have provided in support of my application to verification information suppliers acting on behalf of MIE (including but not
limited to the South African Police Services / Muvoni, the Government of the RSA, and any educational, training, credit bureau and fraud prevention
organisations) for the purpose of verifying my personal credentials and records.
Authorized credential verification types include, but are not limited to, qualifications, professional memberships, employment history, employment references,
consumer credit, criminal record, drivers licence and fraud prevention checks.
I authorize MIEs verification information suppliers to furnish information regarding my credentials, whether claimed or not, to MIE and the Company. I
unconditionally indemnify MIE and its verification information suppliers against any liability that may result from furnishing information in this regard.
I understand that this form is a requirement in terms of the intended transaction therefor my personal credentials will be verified. All information furnished to
the Company and MIE will be disclosed to me.
I authorize MIE to host my fingerprints and upon request, and with my written consent, release results to the requesting organisation.
I understand that all information received from the various verification information suppliers, as part of the background screening process, will be stored by
MIE and made available to various fraud prevention organisations.

01 / 09 / 2015
SIGNATURE

DD

EMAIL ADDRESS:

Hendrik.Dirker@nepean.com

CELLPHONE NUMBER:

082 816 8327

MM

CCYY

As the enquiring Agent of the Company, and in the case that this form instructs MIE to provide consumer credit information, I hereby state that I understand
the provisions of the National Credit Act (34 of 2005), section 70(2)(g), and the Regulations made in terms of the Act, section 18(4) and (5).

/
AGENT SIGNATURE

DD

/
MM

CCYY

All signatories to this document agree that MIE will NOT be held liable for the content, factual correctness or accuracy of any Supplier Data supplied to MIE for
the Company by MIEs suppliers. The Company and the Candidate hereby indemnifies and holds MIE harmless against any loss arising from neglect or
damage in procuring, communicating or failing to communicate information to the Company
Last Updated: September 2013