MIE Consent Form SGL

UPDATED 2021
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:
Full Names:
Maiden Name: Date of Birth:
ID Number / Identifier:
Description of Identifier:
Eg. South African ID Number, Zimbabwean Passport Number, etc.
Residential address ____________________________________________________________________________________________________
Date engaged Occupation applied for
Name of Employer Working place
Have you ever been convicted (found guilty) of a criminal offence or have you ever paid an Admission of Guilt fine, irrespective of whether your
fingerprints were taken or not? (Excluding normal traffic fines for which you did NOT appear in court)
Please mark where it is applicable Yes No
Candidates Signature
Have you been charged for any criminal offence for which you have not yet appeared in court (court date still pending / awaiting trial) or for which
you are still attending court proceedings (pending case / not finalised / awaiting trial / under/pending investigation), irrespective of whether your
fingerprints were taken or not?
Please mark where it is applicable Yes No
Candidates Signature
DETAILS OF CRIMINAL CHARGES (e.g. DATE/ YEAR DATE / YEAR OF DETAILS OF OUTCOME / IS AN APPREAL
Theft, Assault, Assault GBH, Robbery, OF OFFENCE CONVICTION SENTENCE: FINE / AOG / PENDING?
etc.) IMPRISONMENT OR STATUS
CANDIDATE SIGNATURE MOBILE NUMBER DATE
COMPANY AGENT SIGNATURE DATE

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: 14 February 2019 SIBANYE

Personal Credential Disclosure Form
“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 the Company’s duly authorized verification agent, Managed Integrity Evaluation (Pty) Ltd (“MIE”), to access my Personal Information and conduct background screening
checks including, but not limited to, credit, qualifications, employment references, criminal record, fraud prevention, ID verification and drivers’ licence verifications.
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 unconditional, 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 MIE’s other clients for
purposes of continued or future employment or for other legitimate purposes as per the NCA;
Personal Information may be stored for a reasonable period by the Company, MIE and/or the Verification Information Suppliers, and
Personal Information may be transferred cross-border to countries, which do not necessarily have data-protection laws similar to South Africa, for verification or storage purposes. In
any cross-border transfer of personal information the recipient will be notified of the need to protect the confidentiality of the personal information.
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 provisions of POPI or the NCA and I understand that I may dispute any
information in the record provided.
I unconditionally agree to indemnify the Responsible Parties, and Verification Information Suppliers, acting in good faith in taking reasonable steps to process my personal information
lawfully, against any liability that may result from the processing of my personal information. This includes unintentional disclosures of such personal information to, or access by
unauthorized persons, and/or any reliance which may inadvertently be placed on inaccurate, misleading, or outdated personal information, provided to the Company by myself or by a
third party in respect of me.
In authorizing the search/s referred to above, I confirm that I have / have not been forced/ coerced into signing and supplying the above information.
CANDIDATE SIGNATURE MOBILE NUMBER DATE
COMPANY AGENT SIGNATURE DATE

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: 14 February 2019 SIBANYE

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UPDATED 2021

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

Maiden Name: Date of Birth:

Residential address ____________________________________________________________________________________________________

Date engaged Occupation applied for

Name of Employer Working place

Please mark where it is applicable Yes No

Please mark where it is applicable Yes No

CANDIDATE SIGNATURE MOBILE NUMBER DATE

COMPANY AGENT SIGNATURE DATE

COPYRIGHT Last Updated: 14 February 2019 SIBANYE

CONSENT FOR THE USE OF PERSONAL INFORMATION

CANDIDATE SIGNATURE MOBILE NUMBER DATE

COMPANY AGENT SIGNATURE DATE

COPYRIGHT Last Updated: 14 February 2019 SIBANYE

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