APPLICATION FOR MODERATOR REGISTRATION

PERSONAL DETAILS:

Title

First name(s)
Surname
ID number/passport number
Nationality
Date of birth
Gender
Race
Home language

Disability status

CONTACT DETAILS:

Contact number (work)
Contact number (home)
Fax number
Cellphone number
E-mail address
Postal address
Physical address
Town/City
Province


EMPLOYER DETAILS (If applicable)

Name of employer
Address of Employer
Contact person/reference at place of employment
Phone number of contact person

NQF registered qualifications for which you are applying

Title of Qualification(s) / SAQA ID / NQF Level / Credits

NQF registered unit standards for which you are applying

Title of Unit Standard(s) / SAQA ID / NQF level


State below if you have achieved the assessment unit standards.

Attach certified copies of the achieved unit standards and clearly mark them “Annexure A”.

ETDP Registration Number / Provider / Provider Accreditation Number

Moderate Assessment (7977)

Plan & Conduct Assessment (7978)
Design & Develop Assessments (7976)
Verify Moderation of Assessments (7975)

State below the formal qualifications achieved in relation to the unit standards/qualifications on Page Two.

Attach certified copies of these qualifications to your application, and mark this “Annexure B”.

Name
Title of Qualification / Year completed / Name of Provider / Duration of Course

State below the industry/technical experience you have accumulated in relation to the unit standards/qualifications above. Attach a comprehensive CV with references to your application and clearly mark this “Annexure C”.

Name of Employer / Position held / Period / Key
Responsibility Areas

Please complete the declaration form.

DECLARATION:

I / ID number
Certify that the information given in the application to be registered, as a Moderator is correct.
I hereby bind myself and am willing to adhere to the MICT SETA requirements for registered assessors.
Signed by the applicant:

Signature

/ Date:
Witness:
Signature / Date:

All applications should be couriered or posted to MICT SETA at the details below.

MICT SETA ETQA

Postal Address / Physical Address
P O Box 5585
HALFWAY HOUSE
1685
Contact person: Sue Ramphore
Telephone number: 011 207 2600
Fax to Email: 086508 4845 / Block, 2, Level 3 West,
Gallagher House, Gallagher Estates
19 Richards Drive
MIDRAND
E-mail:
Regional Office – Western Cape
P. O. Box 7540
ROGGEBAAI
8012
WESTERN CAPE / The Boulevard Office Park
Block F, Ground Floor
Searle Street
WOODSTOCK, Cape Town
7925
Tel: (021)461 3926
Fax: (021)461 3939
Ms. Audrey Louw

Regional Office – Kwa-Zulu Natal
P. O. Box 763
DURBAN
4000
KWAZULU-NATAL / Durban Bay House,
4th Floor
333 Anton Lembede (former Smith Street)
DURBAN
4001
Tel: (031) 307 7248
Fax: (031) 307 5842
Ms. Lungile Ngcobo

Regional Office – Eastern Cape
P.O. Box 877
21 Oxford Street
EAST LONDON
5200 / Beacon Bay
Phase 2A
Waverley Office Park
CHISELHURST
East London
5205
Tel: (043) 726 0763
Fax: (043) 726 0790
Ms. Nompumelelo Maweni

QA – Moderator Application form V1p0 Charlton Philiso 2014 Page 5