APPLICATION FOR ASSESSOR REGISTRATION

PERSONAL DETAILS:

Title

First Name(s)
Surname
ID Number/ Passport Number
Nationality
Date of Birth
Gender
Race
Home Language

Disability status

CONTACT DETAILS:

Contact Number (Work)
Contact Number (Home)
Fax Number
Cell Phone Number
E-mail address
Postal address
Physical address
Town/City
Province

EMPLOYER DETAILS (If Applicable)

Name of Employer
Address of Employer
Contact person/reference at place of employment
Phone number of contact person

NQF registered Qualifications you are applying for

Title of Qualification(s) / SAQA ID / NQF Level / Credits

NQF registered Unit standards you are applying for

Title of Unit Standard(s) / SAQA ID / NQF Level


State below the formal qualifications achieved in relation to the unit standards/ qualifications above. Attach certified copies of these qualifications to your application, and mark this “Annexure A”.

Name/Title of Qualification / Year Completed / Name of Provider / Duration of Course

State below the industry/technical experience you have accumulated in relation to the unit standards/qualifications above. Attach a comprehensive CV with references to your application and clearly mark this “Annexure B”.

Name of Employer / Position Held / Period / Key Responsible Areas

State below if you have achieved the assessment unit standards. Attach certified copies of the achieved unit standards and clearly mark them “Annexure C”.

ETDP Registration Number / Provider / Provider Accreditation Number

ASSMT01

ASSMT02
ASSMT03
ASSMT04


State below if you have been trained as a trainer, educator or ETDP practitioner. Attach certified copies of these qualifications to your application, and mark this “Annexure D”

Name of Qualification /

Year Completed

/ Provider / Duration of Course

DECLARATION:

I / ID number
Certify that the information given in the application to be registered, as an Assessor is correct.
I hereby bind myself and am willing to adhere to the MICT SETA requirements for registered assessors.
Signed by the applicant:

Signature

/ Date:
Witness:
Signature / Date:

All applications should be couriered or posted to MICT SETA at the details below.

MICT SETA ETQA

Postal Address / Physical Address
P O Box 5585
HALFWAY HOUSE
1685
Contact person: Sue Ramphore
Telephone number: 011 207 2600
Fax to Email: 086508 4845 / Block, 2, Level 3 West,
Gallagher House, Gallagher Estates
19 Richards Drive
MIDRAND
E-mail:

QA – Assessor Application form V1p0 Charlton Philiso 2014 Page 5