Declaration of Consent for Background Screening
I understand and agree that my engagement is conditional to referencing, to the satisfaction of the Registered NCR Agent (NVS) of the
information provided on the Verification Form. I confirm that the information I will provide on the Verification Form will be true and complete to
the best of my knowledge. I Authorise NVS acting on behalf of the client to perform the necessary pre- and post-employment checks on me .
COMPANY/CLIENT INFORMATION
Company/Client Name CATHSSETA Consultant Name
Email Address Contact Number
CANDIDATE/APPLICANT PERSONAL INFORMATION
Name(s) ERNEST MATSOSO Surname MOKUPUTSA
Maiden Name N/A Title (Ms; Mrs; Dr; MR
Prof; Adv.)
Race AFRICAN Gender (Male/Female) MALE
SA ID No./Passport No. 9408245498080 Date of Birth 24/08/1994
Email Address Contact Number 061 927 6551
Matsosoernest5@gmail.com
Physical Address 2657 RATLOU, THABA NCHU, 9780
REQUESTED CHECKS TO BE DONE
ID Credit Qualification Social Media
Verification Checks Employment History Verification Driver’s License Basic
Work Employment Social Media
Permit Fraud Check Confirmation Grade Confirmation PDP Std
Drivers Social Media
Passport **CPA** Character Reference Membership Endorsement Full
Company Reference Check
Citizenship Check Standard NQF Level CCMA Assessment
Reference Check Professional
Asylum Directorship Executive Association Criminal Check Psira
QUALIFICATION DETAILS (copies of qualification must be attached) (WSU please indicate which campus)
Name of Qualification Institution Name Year Completed Campus Name City/Town
MATRIC/SENIOR CERTIFICATE MOTHEO TVET COLLEGE 2020 THABA NCHU THABA NCHU
(COMPULSORY)/ NQF LEVEL 4 CAMPUS
DIPLOMA IN PUBLIC CENTRAL UNIVERSITY OF 2024 BLOEMFONTEIN
MANAGEMENT (NQF LEVEL 6) TECHNOLOGY BLOEMFONTEI
N CAMPUS
National Validation Services 1 Tel: 010 593 1998/info@nvs-sa.co.za
CRIMINAL RECORD DECLARATION
Do you have any Previous Convictions (Criminal Records)? Yes ✘ No
If Yes, please provide the Conviction Details:
N/A
Date Convicted N/A
Offence N/A
What was the sentence N/A
I hereby:
authorise National Validation Services (NVS) acting on behalf of THE CLIENT to verify information presented on my Verification
Form, which may include sensitive personal data for the purpose of the POPI Act 2013 (Act 4 of 2013) and PAIA Act, 2000 (Act 2 of
2000) and obtaining of documents and/or information covered by the Information Regulator of SA and/or application by data
protection legislation.
consent to the Company, its duly authorised agent, National Validation Services (NVS) and its data providers to process my
personal information and conduct background verification checks including but not limited to; credit, criminal, qualifications,
employment references, fraud prevention, ID verification, FAIS comprehensive, professional associations, driver’s licence and social
media;
understand that all personal information is disclosed in confidence and will be kept confidential in a secure manner by the
Company and NVS;
authorise the communication of the results of the background checks to the Company and NVS who, in turn, will keep a copy on
record, as per company policy;
consent to this indemnity form being used from time to time for continued verification purposes for the duration of my engagement
with the Company
authorize NVS to receive and store my personal information for current, future or continued verification purposes (whether for the
Company or for other legitimate purposes); confirm that I have been informed fully of the purposes of the background checks and
that my consent is given voluntarily without coercion and that I may request a copy
of this consent form to retain for my own purposes;
declare that, to the best of my knowledge and belief, all of the information provided in connection with this application is full and
correct and up to date; and undertake to supply any additional information that may be required by NVS to verify the information
given and will inform the Company of any alteration to the information provided. I am aware that:
any information furnished to the Company will be disclosed to me upon request and that I may dispute any information in the
record as prescribed in the Protection of Personal Information Act 4 of 2013 or the National Credit Act 34 of 2005 (NCA);
the Company is responsible for verifying the accuracy of information furnished by the South African Police Service;
where my personal history requires background checks to be carried out in other countries where I have worked, studied or
resided, my data may be transferred to and processed in the other countries, where the data protection laws may not be as strict;
• " in processing my personal information, the Company or NVS may have access to personal information of mine that is sensitive,
including information about criminal behaviour related to the commission of or alleged commission of offences and my credit
history;
I have the right to withdraw my consent at any time by informing the Company that I wish to do so by completing the appropriate
Withdrawal of Consent Form. I am also entitled to object to the processing of my personal information and to obtain a copy of my
personal information at any time; the Company or NVS may contact me and my referees by telephone, email, or post for the
purposes set out above;
verification requests form part of the background screening process;
requests for credit information will only be conducted under the regulations of the NCA and data obtained from the Financial Sector
Conduct Authority serves only for the purposes of determining the fitness and proprietary as envisaged in the Financial Advisory
and Intermediary Services Act 37 of 2002; requests for consumer credit information will be provided for the below prescribed
purposes only:
considering me for employment in a position that requires honesty in dealing with cash and/or finances (as per relevant
job description);
fraud detection and fraud prevention services;
for the purpose of criminal background checks, my fingerprints will be captured and stored for a reasonable period. Any previously
captured fingerprints may be used, where available;
the purpose of background screening, including any social media checks, is for consideration of the results by the Company as part
of my application and/or my suitability for employment;
the social media information that may be covered in the background checks includes all social media accounts of which I am a
member or user, and is not limited to the social media information listed on page one .
INDEMNITY
All signatories agree that NVS, the Company, referees in my CV and/or the data providers shall not incur liability, and no claims will be made for any
compensation in respect of any document or information obtained through such inquiries conducted in good faith. Furthermore, NVS and the Company
will not be held liable for relying on any inaccurate, misleading or outdated personal information provided by the data provider/s or the candidate
Applicant/Candidate Client/Consultant
Signed at THABA NCHU Signed at
On DD/MM/YY 03 DECEMBER 2024 On DD/MM/YY
(date) (date)
National Validation Services 2 Tel: 010 593 1998/info@nvs-sa.co.za
Declaration of Consent for Background Screening
Applicant Name ERNEST MATSOSO MOKUPUTSA Client/Consultant
Name
Applicant Client Signature
Signature
Client Name CATHSSETA
Position Applied For
Full Name & Surname of
Candidate:
Applicant Cell/Contact No.:
Company 1
Name of Organisation
Referees Name & Surname
Referees Position
Office Number
Cell Number
Email
Applicants Position at the Company
Employment Period: YYYY/MM/DD TO YYYY/MM/DD
Company 2
Name of Organisation
Referees Name & Surname
Referees Position
Office Number
Cell Number
Email
Applicants Position at the Company
Employment Period: YYYY/MM/DD TO YYYY/MM/DD
Company 3
Name of Organisation
Referees Name & Surname
Referees Position
Office Number
Cell Number
Email
Applicants Position at the Company
Employment Period: YYYY/MM/DD TO YYYY/MM/DD
Company 4
Name of Organisation
Referees Name & Surname
Referees Position
Office Number
Cell Number
National Validation Services 1 Tel: 010 593 1998/info@nvs-sa.co.za
Email
Applicants Position at the Company
Employment Period: YYYY/MM/DD TO YYYY/MM/DD
Indemnity Declaration To be completed by Candidate - SIGN and DATE
Applicant Signature: Date: 03 December 2024
National Validation Services 2 Tel: 010 593 1998/info@nvs-sa.co.za
