Employment Application Form
Personal Information
Position applied for
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Where did you hear about this position?
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Name
*
First Name
Last Name
ID number
*
Population Group (e.g., African, Coloured, Indian, White)
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Gender
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Female
Male
Other
Population Group
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African
Coloured
Indian
White
Do you have a disability as defined by the Department of Labour?
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Yes
No
If yes, please specify your disability:
Are you a South African Citizen?
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Yes
No
No but I have a permit to work in SA
Contact Details
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Qualifications & Experience
Do you meet the minimum experience as outlined in the advertisement?
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Yes
No
Please indicate the number of years you have worked in a comparable or related position.?
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Do you have the correct qualification, license and/or registration as outlined in the advertisement?
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Yes
No
Qualification Information
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Professional Registration Information Note** if you are not registered with any professional body, kindly indicate N/A or Not Applicable to the following sections:
General Declarations
Do you have any physical health limitations that will prevent you from performing the job applying from?
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Yes
No
If yes, please specify your qualifications:
Occupational Health Risk Declaration In the course of performing your normal duties, and where applicable, you may be exposed to certain occupational health risks. These may include, but are not limited to, manual handling of patients or equipment, exposure to latex, exposure to radiation, and contact with chemicals. If you currently have, or are aware of, any medical condition that may be aggravated by these risks and could impact your ability to carry out your duties safely and effectively, you are required to disclose this information. Examples of such conditions include musculoskeletal issues (such as back, neck, shoulder, or knee pain), allergic reactions (such as dermatitis, latex sensitivity, or asthma), pre-existing respiratory conditions (such as chronic bronchitis or asthma), or conditions with the potential for malignancy or pre-malignancy. This information is necessary to ensure that appropriate occupational health support and reasonable workplace accommodations can be made where required.
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Yes
No
If yes, please specify your health condition:
Substance Declaration: By signing this declaration, you confirm that you do not suffer from, nor are you currently receiving treatment for, any form of addiction or dependency relating to alcohol, drugs, or medication. Should any such condition arise during the course of your employment, you are obligated to disclose it to management without delay, in the interest of workplace safety and wellbeing. By signing below, I confirm that I have read, understood, and voluntarily agree to the terms and conditions of this declaration.
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References
It is in both your and the Company’s best interest to conduct integrity assessments prior to employment. An integrity assessment involves compiling a comprehensive background check relevant to the responsibilities of the position. This may include, but is not limited to, reference checks with referees provided, verification of qualifications, a SANC registration check (if applicable), and credit and/or criminal record checks. By signing below, you voluntarily consent to an integrity assessment being conducted. You acknowledge that this assessment forms part of the pre-employment selection process and that Cintocare is under no obligation to proceed with your appointment. All information obtained during this process will be treated with the utmost confidentiality and discretion.
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Yes I Agree
No I Do not Approve
Current Employer
Previous Employer
Is there any other information, which may have a bearing on your suitability for the position?
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Yes
No
If yes, please specify:
I hereby declare that all particulars and answers in this application form are true and no material fact has been withheld. I agree that this application and declaration shall be the basis of any contract between the Company and me, that the withholding of any material information or failure to answer the questions correctly will constitute a breach of a condition of my employment (if I am successful in my application) for which I may be dismissed.
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