Personal Credential Disclosure Form

COMPANY DETAILS “Company” To be completed by Company Agent

Company Name: Email:

Agent Name: Mobile No:

CANDIDATE PERSONAL INFORMATION To be completed by the Candidate

Surname: Thema
Full Names: Naledi Mantlala Maiden Name

Mobile Number: 065 826 5822 Date of Birth: 17/01/1994

ID Number / Identifier: 9 4 0 1 1 7 0 3 2 0 0 8 0
Description of Identifier: South African ID Number
E.g. South African ID Number, Zimbabwean Passport Number, etc.

BACKGROUND SCREENING CHECKS To be completed by the Company Agent

Credit Check Sanctions
Qualification Identity Verifications
Employment References Insurance Regulations
Criminal Checks Drivers license & Vehicles
Fraud Check Social Media Screening Checks
DEFINITIONS IN TERMS OF BELOW CONSENT
“Candidate” means the person completing this document to be considered by the Company for purposes of employment/ continuation of employment;
“Company” refers to MIE Client;
“Consumer Credit Information” shall have the meaning ascribed to it in section 70 of the NCA;
“FAIS Act” shall mean the Financial Advisory and Intermediary Services Act of 2002;
“FSCA” refers to the Financial Sector Conduct Authority;
“NCA” shall mean the National Credit Act, No. 34 of 2005, as amended from time to time, including any regulations made under the Act;
“Personal Information” shall have the meaning ascribed to it in Chapter 1 of POPI and includes, but is not limited to a name, address, email address, telephone or fax number, fingerprints, criminal history and education
or other personal credentials provided, or which is collected from the candidate or other third parties, before and/or during the background screening process and/or thereafter;
“POPI” shall mean the Protection of Personal Information Act, No. 4 of 2013, as amended from time to time, including any regulations made under the Act;
“Privacy and Data Protection Conditions” refers to the 8 (eight) statutory prescribed conditions for the lawful Processing of Personal Information;
“Responsible Parties” have meaning to the Company and MIE together, and “Responsible Party” any one of them;
“Verification Information Suppliers” shall mean third parties acting on behalf of MIE, including, but not limited to, criminal record bureaus, credit bureaus, governmental bodies, and any educational, training, and fraud
prevention organisations;

CONSENT FOR THE USE OF PERSONAL INFORMATION

I hereby authorize by signing this form that the Company’s duly authorized verification agent, Managed Integrity Evaluation (Pty) Ltd (“MIE”), to access my Personal Information and conduct
background screening checks as indicated above.
I consent to requests for consumer credit information to be released for the below prescribed purposes only:
For employment in a position of trust and honesty and entails the handling of cash or finances;
Fraud prevention or detection.
I understand that verification requests form part of the background screening process and:
That requests for credit information from Credit Bureaus will only be conducted under the regulations defined as per the NCA;
Data obtained from the FSCA serve only for the purpose to determine the fitness and propriety as envisaged in the FAIS Act.
I acknowledge that any Personal Information supplied to the Company is provided voluntarily and that the Company may not be able to comply with its obligations if the correct Personal
Information is not supplied to the Company.
I understand that privacy is important to the Responsible Parties and the Responsible Parties will use reasonable efforts in order to ensure that any Personal Information in their possession
or processed on their behalf is kept confidential, stored in a secure manner and processed in terms of South African law and or applicable Data Protection Legislation, for the purposes I have
authorised.
I warrant that all information, including Personal Information, supplied to the Company is accurate and current and agree to correct and update such information when necessary.
By submitting any Personal Information to the Company in any form I acknowledge that such conduct constitutes a reasonable un conditional, specific and voluntary consent to the processing
of such Personal Information in the following manner by the Company and/or verification information suppliers:
Personal Information may be shared by the Company with MIE and may be further shared by MIE with the Verification Information Suppliers for verification or other legitimate purposes;
Personal Information may be shared by the Verification Information Suppliers with MIE and be further stored and shared by MIE with the Company and Fraud databases or services
when the information provided for verification is deemed fraudulent by the Verification Information Suppliers for purposes of continued or future employment or for other legitimate
purposes as per the NCA or other National or Provincial Legislation;
Personal Information may be stored by MIE, for legislated retention periods and where such periods are not legislated then my personal information may be stored by MIE for as long
as I may need my information to be verified, or any other period as I may agree with the MIE. and
Personal Information may be transferred cross-border to countries, for verification or storage purposes. In any cross-border transfer of personal information MIE will comply with the
security safeguards as provided for in the POPIA including but not limited to ensuring that the information is secured when transported to or from the recipient.
I take note that if the Responsible Party has utilised the Personal Information contrary to the Privacy and Data Protection Conditions, I may first resolve any concerns with that Responsible
Party. If I am not satisfied with such process, I have the right to lodge a complaint with the Information Regulator.
A copy of Personal Information kept by the Responsible Parties will be furnished to me upon request in terms of the provision s of POPI or the NCA and I understand that I may dispute any
information in the record provided.
“I agree that MIE, to the extent permitted by law, will not be liable for any complaint, claim or action brought by me, arising from any action or omission by MIE, to the extent that such
action or omission resulted from MIE complying with the terms of this consent and I shall indemnify, hold harmless and defend MIE from and against any such claims or actions brought
against MIE.”

CANDIDATE COMPANY AGENT

SIGNATURE Thema N
DATE 2023/12/05
All signatories to this document agree that MIE will NOT be held liable for the content, factual correctness or accuracy of any Supplier Data supplied to MIE for the Company by MIE’s suppliers. The Company and the
Candidate hereby indemnifies and holds MIE harmless against any loss arising from neglect or damage in procuring, communicating or failing to communicate information to the Company.

COPYRIGHT Last Updated: 1 February 2021