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 EmployerAddress 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 / CreditsNQF 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”.
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 AreasState 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 NumberASSMT01
ASSMT02ASSMT03
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”
Year Completed
/ Provider / Duration of CourseDECLARATION:
I / ID numberCertify 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 AddressP 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