Private Security Industry

Regulatory Authority (SIRA)

THE DIRECTOR
PRIVATE SECURITY INDUSTRY Application for registration as a security service
REGULATORY AUTHORITY provider in terms of the Private Security Industry
PRIVATE BAG X817 Regulation Act 56 of 2001 (“the Act”)
PRETORIA
0001 APPLICATION FOR RENEWAL OF
INDIVIDUAL CERTIFICATE

APPLICATION
01 RENEWAL 02 REISSUE 03 UPGRADE

/ 0 7 / 0 5 / 2 0 2 3 Application Date (dd/mm/yyyy)

PARTICULARS OF APPLICANT
South African Identification Number / Permit number / Asylum
9 2 0 7 0 8 0 2 8 2 0 8 2 papers

2 6 2 9 6 8 5 PSiRA Number

k o s e n g Surname

m a r t h a Full Names

PLEASE TICK

CLOSE
MALE FEMALE 03 UPGRADE 04
CORPORATION

PHYSICAL ADDRESS OF APPLICANT

2 6 1 1 u m g a n u s t r e e t

o l i e v e n h o u t b o s c h

c e n t u r i o n

0 1 7 5 Postal Code

POSTAL ADDRESS (if different to Physical Address)

p . o . b o x 2 4 8

k o r i n g p u n t

0 6 3 2 Postal Code

TELEPHONE NUMBERS (Code/Number)

Business Fax 0 6 3 7 3 1 1 1 9 8 Cellphone

maritaboikanyokoseng0708@gmail.com
____________________________________________________ Email address

IS THE APPLICANT EMPLOYED? YES NO

CURRENT EMPLOYER: EMPLOYEE NUMBER:

e l d n a s e c u r i t y 9 2 0 7 0 8

martha 9207080282082
I the undersigned, ______________________________________________________________________________________
Full name and identity number

Page 1 of 3 Pages
declares that the information furnished on this form is true and complete to the best of my knowledge. I agree that Private Security
Industry Regulatory Authority may summarily approve\rejects my application in case any of the information/record(s) furnished above
found to be incorrect or false and I will not make any correspondence in the matter whatsoever and I will abide by the decision of the
Private Security Industry regulatory Authority.

Verified by pdfFiller

THUS DONE AND SIGNED at 05/07/2023 olieven on 7may 23

Of 20____

SIGNATURE: M.m koseng

FOR OFFICE USE ONLY

1. Purpose of the visit collection of new certificate/ re issue/upgrade
2. Confirmation of registration with PSIRA YES/NO
3. Confirmation of Grades or any other course YES/NO
4. Confirmation of ID/ Permit/passport with DHA YES/NO
5. Proof of employment (Proof of Pay slip or Affidavit) YES/NO
6. Update of the postal and physical address YES/NO
7. Proof Old certificate/affidavit if case of lost, theft etc YES/NO
8. Total amount to be paid R

I have confirmed the above to be correct

Name of PSIRA official-------------------------------- Signature--------------------------------------------

Date ------------------------------------------------------

Page 2 of 3 Pages
 Security Industry Regulatory Authority
Renewal of certificate Checklist - Individual
Name martha koseng

Date 07/05/2023

REQUIREMENT

1. Duly completed application form (Renewal of individual certificate form)

2. Payment of prescribed amounts (R30.00 First issue / R50 Re issue)

3. Authenticated copy of first page of ID document/ Permanent/ Work permits/ Asylum papers

4. Proof of pay slip or affidavit (if employed)

5. Proof of old certificate or affidavits in case of loss , theft etc

Page 3 of 3 Pages