Form 1 B
PARTICULARS OF THE NOMINEE
1. Title of nominee: Mr/Ms/Dr/Prof/Other: _________
2. Surname: (as on ID)
3. Full Names: (as on ID):
4. Biographic Information:
RSA Citizen Yes
No
ID Number
Race
African
Asian
Gender
Disability
Male
Yes
Coloured
White
Female
No
5. Is the nominee currently a member of the Board/Tribunal: Yes / No
6. Contact Details of the Nominee:
Work Telephone
Number
Home
Telephone
Number
Mobile Number
Email Address
Postal Address
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7. Is the nominee an un-rehabilitated insolvent? Yes / No
If “Yes” please complete or attach details
8. Has the nominee ever been convicted of any offence: Yes / No
If “Yes” a. Please complete or attach details; and
b. Provide date on which last sentence was served:
9. Is there any matter that may disqualify the nominee for service on
this entity? Yes / No
If “Yes” Please provide or attach details:
10. List/describe the relevant fields of expertise of the nominee:
e.g. conditions of service, salaries, policy development, negotiation, etc.
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11. Provide details about the proven skills, knowledge and experience
of the nominee:
12. What are the academic qualifications of the nominee? Please
complete the following detail:
Qualification
Year Obtained
Institution
13. Sample of publications published by nominee: Please attach
14. Full CV of the nominee: Please attach
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