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H U M A N R ES O U R C E S

ADMINISTRATIVE QUESTIONNAIRE

COMPLETE FORM IN PRINT / UT-NUMBER
1. / PERSONAL DETAIL
Surname
First names(In full)
Maiden name
Title(Prof/Dr/Mr/Ms/Mrs)
Nationality (e.g. SA citizen)
Gender(Male or Female)
Race(Mark with X) / Asian/Indian / African / Coloured / White
(information required by statute for statistical purposes)
Date of birth(d/m/y)
Identification number
Passport number –
Country where passport was issued / (Attach copy of passport)
Expiry date(d/m/y)
Work permit number / (Attach copy of work permit)
Country where work permit was issued
Expiry date(d/m/y)
Residentialpermit (Mark with X) / YES / NO / (Attach copy of residence permit)
Marital status
Income tax number
Income tax office
Telephone number / Work
Home
Cellphone
Postal address
Postal code
Street address
Postal code
Home language / Afrikaans / English / Other (specify)
Language of correspondence / Afrikaans / English
(preference)
Are you disabled?(Mark with X) / YES / NO
If the answer is YES, state the nature of disability
NOTE: “People with disabilities” refers to people with a long-term or recurring physical or mental impairment that substantially limits their prospects of entry into, or advancement in employment.
Are youpermanently employed at another institute other than Stellenbosch University(Mark with X) / YES / NO
2. / PARTICULARS OF UNMARRIED CHILDREN, ADOPTED CHILDREN AND/OR STEPCHILDREN STILL TOTALLY DEPENDENT
Under 21 years of age – First names and surname / Date of birth
D / D / M / M / Y / Y / Y / Y
Over 21 years of age – First names and surname / Date of birth
D / D / M / M / Y / Y / Y / Y
3. / QUALIFICATIONS
D / D / M / M / Y / Y / Y / Y
Degrees/Diplomas/Certificates/Highest standard attained / Institution where attained / Date when attained
4. / FIRST NAMES, SURNAME AND DATE OF BIRTH OF SPOUSE/LIFELONG COMPANION
D / D / M / M / Y / Y / Y / Y
Mention full names and surname / Date of birth
Is your spouse/lifelong companion employed by Stellenbosch University? / NO / YES
(Mark with X)
If yes, Faculty/Department/Division
5. / BANK/FINANCIAL INSTITUTION AT WHICH SALARY SHOULD BE DEPOSITED. (To be certified as correct by bank/financial institution.)
Name of bank/financial institution / Branch code
Address
Postal code
Type of account(Mark with X) / Cheque / Savings
Account holder relationship (Mark with X) / Joint / Own / Third party
Account number
Account holder’s name
(if not your own)
The account number must be certified by the bank or proof of the account number must be attached e.g. a cancelled cheque. (If not available, please supply the information to this office as soon as possible after assuming duty.)
CERTIFYING BY FINANCIAL INSTITUTION
Hereby certify that the abovementioned account number is correct
SIGNATURE FOR FINANCIAL INSTITUTION / OFFICIAL DATE STAMP
6. / NAME AND ADDRESS OF EMPLOYER PRIOR TO APPOINTMENT AT STELLENBOSCH UNIVERSITY
Name of prior employer
Postal address
Postal code
Street address
Postal code
7. / PARTICULARS OF APPOINTMENT AT STELLENBOSCH UNIVERSITY
Position
Faculty/Department/Division
Appointment date (d/m/y)
Commencementdate (d/m/y)
Name of supervisor
UT-number of supervisor
8. / DECLARATION/MEDICAL SCHEME/ACCEPTANCE OF APPOINTMENT
DECLARATION/MEDICAL SCHEME/ACCEPTANCE OF APPOINTMENT
Declaration
I, the undersigned, hereby declare that:
  • I have never been convicted of any criminal offence by a competent court;
  • I have never been convicted by a previous employer of fraud, theft, corruption, bribery or dishonesty, nor have I been dismissed from a job based on a conviction thereof or resigned due to such behavior;
  • I, with the acceptance of the appointment at Stellenbosch University, am not appointed elsewhere;
  • this declaration is made voluntarily and the content hereof is correct; and
  • I accept and agree that the Stellenbosch University may summarily dismiss me if at any stage it appears that the above statement is false.
Medical Scheme
I,the undersigned:
  • am in agreement with the University that the contributions to the medical scheme take place on a basis of income abdication. This means that I waive a portion of my income. The part that I waive is equal to the medical premium paid to Discovery Health. This premium is fully sponsored by the University, as employer pays and the effect is that I, as an employee,earn less.
Not applicable for:
or when: / - Job Grade 13 – 19
- dependant on spouse’s medical scheme (attach proof of membership)
Acceptance of Appointment
I, the undersigned, recognize that:
  • I accept the appointment as in point 7 above;;
  • I understand the full implications of my cost of employment;
  • I have read and accepted the attached documentation;
  • I am bound to consider all the conditions of service laws, codes and procedures as well as, regulations of the University;
  • the information contained in this form is true and correct.

SIGNATURE OF EMPLOYEE / DATE(d/m/y)
9. / DECLARATION BY CURRENT EMPLOYER WITH REGARD TO THE PAYMENT OF ACCUMULATED ANNUAL STUDY LEAVE PRIVILEGES
Accumulated Study Leave Privileges
A / Accumulated annual study leave to person's credit at termination of employment (calendar or working days)
B / Years of service given up to study leave, earned at termination of employment / Years / Months
CERTIFIED AS CORRECT / OFFICIAL DATE STAMP
10. / NAME OF CURRENT EMPLOYER

Administrative Questionnaire/MH Vorms/Administratief (August 2012)

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