HR-Pol-Rec&Res-04 Employment Application Form (Recruitment of Permanent Employees) Instructions

Enter the mailing address where you receive post (PO Box or street mailing address), including any box number, suburb and city.

Enter your full current residential address (street, suburb, city and any unit or house number) as a single text string.

Enter the postal or ZIP code for your postal address.

Enter the applicant's initials (letters used to represent their first and any middle names).

Enter the name the applicant is commonly known by or prefers to be called (nickname or preferred first name).

Enter the applicant's legal first or given name as shown on official documents.

Enter the applicant's legal family or last name as shown on official documents.

Enter full details of any personal business interests or directorships (company name(s), position(s) held, nature of the business, relevant dates and any ownership percentage or remuneration received). Fill only if 'Personal Business Interests / Director - Yes' is 'Yes'.

Check this box if you do not have any personal business interests and you are not a director of a private company or close corporation.

Check this box if you have personal business interests or you are a director of a private company or close corporation.

Enter the short header or label for the Contact Details section (for example: 'Contact Details' or any brief note identifying this section).

Enter the total number of COVID-19 vaccine doses you have received (e.g., 1, 2, 3). Fill only if 'Vaccinated — Yes' is 'Yes'.

Enter the name of the COVID-19 vaccine you received (for example: Janssen, Pfizer, Moderna). Fill only if 'Vaccinated — Yes' is 'Yes'.

Enter 'Yes' to indicate that you have been vaccinated against COVID-19.

Enter 'No' to indicate that you have not been vaccinated against COVID-19.

Enter your current total remuneration amount and currency (specify whether this is annual or monthly pay).

Enter the fourth digit of your date of birth as shown on the form (digits are entered left-to-right for year, month, and day).

Enter the fifth digit of your date of birth as shown on the form (digits are entered left-to-right for year, month, and day).

Enter the first (leftmost) digit of your date of birth as shown on the form (digits are entered left-to-right for year, month, and day).

Check this box when completing the rightmost digit position of the Date of Birth field (the final digit shown on the form).

Check this box when completing the second digit position of the Date of Birth field (the digit immediately to the right of the leftmost box).

Enter the third digit of your date of birth as shown on the form (digits are entered left-to-right for year, month, and day).

Check this box when completing the leftmost digit position of the Date of Birth field (the first digit shown on the form).

Enter the second digit of your date of birth as shown on the form (digits are entered left-to-right for year, month, and day).

Check this box when completing the highlighted year digit position of the Date of Birth field (the year digit indicated by this box on the form).

If you answered Yes to having a disability as defined by the Department of Labour, enter a brief description of the disability or impairment here. Fill only if 'Disability (Dept of Labour) - Yes' is 'Yes'.

Check this box if you have a disability as defined by the Department of Labour.

Check this box if you do not have a disability as defined by the Department of Labour.

Enter the small section identifier for the Employment Preference section (typically the number '1').

Check this box if you are applying for or are available for a part-time position.

Check this box if you are not applying for and are not available for a part-time position.

Check this box if you are applying for or are available for a full-time position.

Check this box if you are not applying for and are not available for a full-time position.

Enter the job title or role of the contact person at the referenced company.

Enter your position or role at that company associated with this first reference.

Enter the full name of the contact person for this first reference (for example, Jane Doe).

Enter the name of the company or organization for your first reference.

Enter the contact person's telephone number for this reference, including country and area code if applicable.

Check this box if you identify your gender as Male.

Check this box if you identify your gender as Female.

Enter the second single digit of your identity/ID number exactly as it appears on your identity document.

Enter the seventh single digit of your identity/ID number exactly as it appears on your identity document.

Enter the fifth single digit of your identity/ID number exactly as it appears on your identity document.

Enter the third single digit of your identity/ID number exactly as it appears on your identity document.

Enter the fourth single digit of your identity/ID number exactly as it appears on your identity document.

Enter the sixth single digit of your identity/ID number exactly as it appears on your identity document.

Enter the first (leftmost) single digit of your identity/ID number exactly as it appears on your identity document.

Enter the short title or label for this general section header (for example 'General' or a brief section name) that appears at the right of the header.

Enter the short index or identifier for this general section (e.g., a small numeric code or short label) that appears at the left of the header.

Provide a clear description of the health condition(s) relevant to this disclosure, including the condition name, symptoms, how it may be worsened, and any information that could impact your appointment.

Enter the third digit of your ID number (one numeric character) into this box as it appears on your identity document.

Enter the sixth digit of your ID number (one numeric character) into this box as it appears on your identity document.

Enter the fourth digit of your ID number (one numeric character) into this box as it appears on your identity document.

Enter the second digit of your ID number (one numeric character) into this box as it appears on your identity document.

Enter the fifth digit of your ID number (one numeric character) into this box as it appears on your identity document.

Enter the first digit of your ID number (one numeric character) into this box as it appears on your identity document.

Enter your initials to confirm you have read and consent to the company performing the integrity assessments described in this section.

Enter the name or location of the facility/site where you want to work.

Enter the job title or position you are applying for at this organization.

Enter where you heard about this position (for example: job board name, company website, newspaper, recruitment agency, employee referral with name, social media platform, or other source).

Enter the country that issued your license or registration. Fill only if 'Has License — Yes' is 'Yes'.

Enter the expiry date of your license or registration. Fill only if 'Has License — Yes' is 'Yes'.

Enter the renewal date for your license or registration. Fill only if 'Has License — Yes' is 'Yes'.

Enter the name of the organization or authority that issued or registers your license. Fill only if 'Has License — Yes' is 'Yes'.

Enter the type or category of the registration or license (for example the professional title or qualification). Fill only if 'Has License — Yes' is 'Yes'.

Enter the date your license or registration was issued. Fill only if 'Has License — Yes' is 'Yes'.

Enter the registration or license number assigned to you. Fill only if 'Has License — Yes' is 'Yes'.

Enter 'Yes' to indicate you have a license or registration to perform the work you are applying for.

Enter 'No' to indicate you do not have a license or registration to perform the work you are applying for.

Check this box when you do NOT give Life Healthcare permission to contact the references you listed above.

Check this box when you give Life Healthcare permission to contact the references you listed above.

Enter the short header or title text that will appear above the personal details portion of the form (for example, 'Personal Details' or a custom section heading).

Enter your primary landline telephone number, including area code if applicable.

Provide an alternate contact telephone number (mobile or other) where you can be reached.

Enter your mobile/cell phone number, including country or area code if required.

Check this box if you have never previously submitted an application to work at Life Healthcare.

Check this box if you have previously submitted an application to work at Life Healthcare.

Enter the job title or position you held at the Life Healthcare hospital or business unit you listed above.

Enter the name of the Life Healthcare hospital or business unit where you previously worked. Fill only if 'Previously worked at Life Healthcare - Yes' is 'Yes'.

Check this box if you HAVE previously worked at a Life Healthcare hospital or business unit.

Check this box if you have NOT previously worked at a Life Healthcare hospital or business unit.

Enter the code or short text identifier the form expects to indicate the applicant’s race as 'Asian'.

Enter the code or short text identifier the form expects to indicate the applicant’s race as 'Coloured'.

Enter any additional notes or details for Reference 1, such as brief comments, clarifications, or other information related to this reference or contact.

Enter the full name(s), relationship(s) to you, and the department/position (and employee number if known) for any relative currently employed by Life Healthcare. Fill only if 'Relatives Employed by Life Healthcare — 2' is 'Yes'.

Check this box if you have one relative currently employed by Life Healthcare.

Check this box if you have two relatives currently employed by Life Healthcare.

Enter the job title or role of the contact person listed for your second reference.

Enter the full name of the company or organization for your second reference.

Enter the full name (first and last) of the contact person for your second reference.

Enter the job title or role held by your second reference at that company.

Enter the contact person's phone number for your second reference, including country and area code if applicable.

Check this box if you are a South African citizen.

Check this box if you are not a South African citizen (you will then be asked whether you have a permit to work in South Africa).

Enter the full name of the contact person who can provide this reference.

Enter a phone number where the contact person can be reached, including area and country codes if applicable.

Enter the job title or role of the contact person at the company.

Enter the full name of the company for your third reference.

Enter the job title or position you held at that company relevant to this reference.

Check this box if you are NOT a South African citizen and you DO NOT have a permit to work in South Africa. Fill only if 'Are you a South African Citizen? — No' is 'Yes'.

Check this box if you are NOT a South African citizen and you DO have a valid permit to work in South Africa. Fill only if 'Are you a South African Citizen? — No' is 'Yes'.