THE DIRECTOR Private Security Industry
PRIVATE SECURITY INDUSTRY
REGULATORY AUTHORITY Regulatory Authority (SIRA)
PRIVATE BAG X817
PRETORIA Application for registration as a security service
0001 provider in terms of the Private Security Industry
Regulation Act 56 of 2001 (“the Act”)
APPLICATION FOR RENEWAL OF
INDIVIDUAL CERTIFICATE
APPLICATION
01 RENEWAL 02 RE-ISSUE 03 UPGRADE
0 1 / 0 2 / 2 0 2 4 Application Date (dd/mm/yyyy)
PARTICULARS OF APPLICANT
South African Identification Number / Permit number / Asylum
8 8 0 7 0 6 6 1 0 0 0 8 2 papers
1 9 3 2 7 2 8 PSiRA Number
m a d a l a Surname
l e s o l e w i i l w i i l s o n Full Names
PLEASE TICK
CLOSE
MALE FEMALE 03 UPGRADE 04
CORPORATION
PHYSICAL ADDRESS OF APPLICANT
s t a n d n o 5 4 4
b o t l o k w a g a m a k g a t o
l e t j a t j a n a
0 8 6 7 Postal Code
POSTAL ADDRESS (if different to Physical Address)
b o x 9 6
d w a r s r i v e r
0 8 1 2 Postal Code
TELEPHONE NUMBERS (Code/Number)
Business Fax 0 7 1 2 3 4 4 1 9 3 Cellphone
____________________________________________________ Email address
IS THE APPLICANT EMPLOYED? YES NO
CURRENT EMPLOYER: EMPLOYEE NUMBER:
e n v i r o m o n g s p r o j e c t 2 2 0 8 0 7 3
Page 1 of 2 Pages
lesole Wilson 8807066100082
I the undersigned, ______________________________________________________________________ (Full Name and identity number)
declare that I have taken note of the minimum requirements for registration and that the information furnished on this application form is,
to the best of my knowledge, true and complete. I agree that the Private Security Industry Regulatory Authority may summarily
approve\reject my application in case any of the information\record(s) furnished above are found to be incorrect or false and will not make
any correspondence in the matter whatsoever, I will abide by the decision of the Private Security Industry Regulatory Authority.
THIS DONE AND SIGNED at 01 on 02 24
Of 20_____
Verified by pdfFiller
02/01/2024
SIGNATURE:
FOR OFFICE USE ONLY
1. Confirmation of registration with PSiRA YES/NO
2. Confirmation of Grades or any other course YES/NO
3. Confirmation of identification with DHA YES/NO
4. Payment confirmed YES/NO
I hereby confirm that the application was complete and correct
Name of PSiRA official___________________ Signature____________________
Date _______________________
Page 2 of 2 Pages
