Application Form to Register Assessor
Application to Register as an Assessor
Purpose of this form:
Should you wish to register as an assessor please complete all details on this form.
1Applicant Details
Title / Mr. / Mrs. / Miss. / Dr. / Prof. / Other, SpecifyLast Name (Surname)
First Name
Middle Name (s)
Telephone Number
Cell Phone Number
Facsimile Number
E-mail Address
Residential (Home) Address
Code
Postal Address
Code
Province / Eastern
Cape / Northern
Cape / Western
Cape / Free
State / KZN / Mpumalanga / Limpopo / Gauteng / North
West
Town / ______
Date Of Birth / y / y / y / y / m / m / d / d
Identification Type Document / ID Book / Driver’s
License / Passport / Student
Number / Work Permit
Number / Other, Specify
Identification Number (Attach Copy)
Home Language / Eng / Afr / isi
Zulu / tsi
Tsonga / se
Pedi / se
Sotho / se
Tswana / si
Swati / tshi
Venda / tsi
Xhosa / tsi
Ndebele
Gender /
Male
/ FemaleRace / Black / Coloured / Indian / White / Other, Specify
Disability Status / None / Hearing / Physically / Sight / Speech /
Other, Specify
Socio-economic Status / Employed / Unemployed / Student / Other, SpecifyHighest Tertiary Qualification
2Provider YOU ASSESS FOR: (if there is agreement with provider)
Provider NameAccreditation Number
Telephone Number
Facsimile Number
E-Mail Address
Street Address
Code
Postal Address
Code
Province / Eastern
Cape / Northern
Cape / Western
Cape / Free
State / KZN / Mpumalanga / Limpopo / Gauteng / North
West
Contact Person
Designation
Telephone Number
Facsimile Number
Cell Phone Number
E-Mail Address
Note:If applying for registration against a Qualification, complete section 1.
If applying for registration against a Unit Standard, complete section 2.
3Specific information
1.Name(s),NQF level(s) and SAQA ID number of qualification you wish to be registered against: Eg: Plant Production, Animal Production or Farming
NAME OF QUALIFICATION (S) / NQF LEVEL / BAND / SAQA REGISTRATIONNUMBER (ID)2.Name(s),NQF level(s) and SAQA ID number of unit standard(s) you wish to be registered against (only to be completed if the unit standard is not included in the unit standard-based qualification listed in the Table above)
NAME OF UNIT STANDARD (S) / NQF LEVEL / BAND / SAQA REGISTRATION NUMBER (ID)3.Summary of educational qualification of the applicant:
QUALIFICATION (S) TITLE / PROVIDER /YEAR OBTAINED
/ NQF LEVEL / BANDy / y / y / y / m / m / d / d
y / y / y / y / m / m / d / d
y / y / y / y / m / m / d / d
y / y / y / y / m / m / d / d
4.Summary of assessor training attended by the applicant:
UNIT STANDARD TITLE /PROVIDER
/YEAR OBTAINED
/NQF LEVEL / BAND
y / y / y / y / m / m / d / dy / y / y / y / m / m / d / d
5.Copy of assessor certificate obtained with a provider accredited with the ETDP SETA, attached:
YES / /NO
/ 6.Copy of proof that applicant is a subject matter expert, attached:
YES
/ /NO
/ 7.Please tick the relevant box:
Independent Assessor
/ Company/Provider based Assessor
/ 4Declaration
I ______hereby declare that the information provided is according to my knowledge correct.
Signature: ______Date: ______
FOR AgriSETA OFFICE USE ONLYDate of receipt of application
Registered by:
Registration number:
Registered at the Office of the AgriSETA this ______day of ______of 20 ______
SUPPORTING DOCUMENTS
ASSESSOR
- Certified copy of ID
- Detailed CV
- Certified copy of ETDP SETA Statement of Results
- Certified copies of Proof of Subject Matter Expertise certificates (Qualifications)
- Certified copy of Competence as an Assessor certificate
Kindly note that Assessors and Moderators cannot be registered
simultaneously.
After registering as an Assessor within the AgriSETA, the applicant must doabout 20 assessments, and submit the proof to us .
Please make sure that all the documents are certified.
Effective Date: / Revision Date: / Page 1 of 5