Private Security Industry Regulatory Authority (SIRA)

THE DIRECTOR PRIVATE SECURITY INDUSTRY REGULATORY AUTHORITY PRIVATE BAG X817 PRETORIA 0001 Private Security Industry Regulatory Authority (SIRA) Application for registration as a security service provider in terms of the Private Security Industry Regulation Act 56 of 2001 ( the Act ) APPLICATION BY AN INDIVIDUAL (NATURAL PERSON) [SIRA-1] Identity Number Date of birth (CCYY/MM/DD) Surname First names PSIRA Number of Security Officers (if any) Male/Female (M/F) RESIDENTIAL ADDRESS Certified photograph of applicant s face (passport size) Postal Code POSTAL ADDRESS (if different to residential address) How would you prefer to receive your post from the Authority? (Mark with an X ) Mail to postal address Mail to physical address Collect at local Authority office: PRETORIA DURBAN Postal Code CAPE TOWN TELEPHONE NUMBERS (Code/Number) Home Cellphone (compulsory) PORT ELIZABETH PIETERSBURG Work NELSPRUIT E-MAIL ADDRESS EMPLOYMENT STATUS Nature of current employment NAME AND ADDRESS OF CURRENT EMPLOYER Postal Code Employer s SIRA Registration. Employee. Date of commencing employment with present employer (CCYY/MM/DD) 1

Indicate the nature of the security service/s performed/to be performed (mark with X ) 01 05 09 13 GUARDING AND/OR PATROLLING: COMMERCIAL, INDUSTRIAL OR RESIDENTIAL PROVIDING REACTION OR RESPONSE SERVICES PROVIDING, SECURITY TRAINING OR INSTRUCTION MAKING PERSONS OR THEIR SERVICES AVAILABLE FOR RENDERING OF A SECURITY SERVICE 02 06 10 14 SAFEGUARDING ASSETS IN TRANSIT/PROVIDING SECURE TRANSPORT ENSURING SAFETY AND ORDER ON PREMISES (SPORTING, RECREATIONAL, ENTERTAINMENT) INSTALLING, SERVICING OR REPAIRING SECURITY EQUIPMENT PROVIDING SECURITY AT SPECIAL EVENTS 03 07 11 15 PROVIDING CLOSE PERSONAL PROTECTION/ BODYGUARDING MANUFACTURING, IMPORTING, DISTRIBUTING OR ADVERTISING OF MONITORING DEVICES PROVIDING SERVICES OF A LOCKSMITH CAR WATCH OR RELATED ACTIVITIES 04 08 12 16 PROVIDING ADVICE ON THE PROTECTION OF PERSONS OR PROPERTY, ANY OTHER SECURITY SERVICE OR THE USE OF SECURITY EQUIPMENT FUNCTIONING AS PRIVATE INVESTIGATOR MONITORING SIGNALS FROM ELECTRONIC SECURITY EQUIPMENT (SECURITY CONTROL ROOM) OTHER (Please specify below) CITIZENSHIP SOUTH AFRICAN CITIZENSHIP VALID PERMANENT RESIDENCE PERMIT FOR SOUTH AFRICA PERMIT NUMBER DATE OF ISSUE If not a South African citizen, state all the countries in which you have citizenship State all the countries in respect of which you hold a valid passport. To be completed by all persons that are not South African citizen nor hold permanent residence status and who wish to avail themselves of the provisions of Section 23(6) of the Act in applying for registration. Describe your status within the country. i.e. refugee, temporary residence permit, visitor s permit, study permit, work permit etc Have you applied for permanent residence status or do you qualify for citizenship and the status of such application or qualification? The length of your stay in the country and supporting evidence Can you provide a criminal record clearance certificate from the South African Police Service for your length of stay in the country? Can you submit proof of a criminal record clearance from your country of origin and other countries you resided in as contemplated in Regulation 2(6) of the Private Security Industry Regulations, 2002 and if not, reasons for not being able to do so. 2

Did you previously work in a similar or comparable industry? Reference from the previous employment must be submitted. Any other written reference from previous employment as well as character Describe your personal circumstances for seeking registrations and subsequent employment within the private Security Industry Describe the character/type of work you intend performing, in the Private Security Industry Any other relevant information you feel the Authority should take into consideration to objectively consider the application QUESTION 1 Have you ever been convicted of a criminal offence outside South Africa? If yes, furnish particulars QUESTION 2 Have you resided outside South Africa for an uninterrupted period of at least 1 year during the 10 year period immediately preceding this application? COUNTRY PERIOD OF RESIDENCE FROM TO If yes, give particulars of the countries and places where you have resided and indicate the period of residence. QUESTION 3 Are you presently or have you ever been employed as a member of any official military, security, police, intelligence force or service in South Africa or elsewhere? NAME OF FORCE/SERVICE AND FORCE NUMBER PERIOD OF SERVICE FROM TO If yes, give particulars of every such force or service, with the dates of your service. 3

QUESTION 4 Have you ever been declared to be of unsound mind by a court of law? If yes, furnish particulars. QUESTION 5 Have you ever received medical treatment for a mental illness or disease in a public or private hospital or institution in South Africa or elsewhere? NAME OF INSTITUTION PERIOD OF TREATMENT FROM TO If yes, furnish particulars. QUESTION 6 Have you ever been declared insolvent? If yes, furnish the date and state whether you have been rehabilitated QUESTION 7 Is there currently a criminal investigation by the State into an alleged offence by you or are there criminal proceedings in a court pending against you? ALLEGED CRIMINAL OFFENCE POLICE STATION/ COURT REFERENCE NO. If yes, furnish particulars. QUESTION 8 Has the registration as security officer or security service provider of any security business or the accreditation of any security training establishment in which you have been involved ever been withdrawn? NAME OF BUSINESS/TRAINING ESTABLISHMENT SIRA REFERENCE NUMBER DATE OF WITHDRAWAL If yes, furnish particulars. QUESTION 9 Has any security business or security training establishment in which you have been involved as an owner, director, member, partner, trustee or manager ever been liquidated, sequestrated or wound up? NAME OF BUSINESS/TRAINING ESTABLISHMENT SIRA/SOIB REFERENCE NUMBER DATE OF LIQUIDATION/ SEQUESTRATION/ WINDING UP If yes, furnish particulars 4

10 QUESTION 10 Has the registration as security officer or as security service provider of any immediate family member of yours (spouse, father, mother, son, daughter, brother or sister) or of any security business in which any such person has been involved as an owner, director, member, partner, trustee or manager, ever been withdrawn? NAME SIRA/SOIB REFERENCE NUMBER DATE OF WITHDRAWAL If yes, furnish particulars. QUESTION 11 Please furnish the full first names, surnames and ID numbers of 5 persons who can be described as your next of kin (your closest living relatives) QUESTION 12 Are you presently or do you intend to be an owner, manager, director, member, partner or trustee of a security business? If yes, furnish particulars. FULL NAME OF BUSINESS BUSINESS REGISTRATION NUMBER OWNER/DIRECTOR/MEMBER/ PARTNER/TRUSTEE/ ADMINISTRATOR Declaration by applicant: I, the undersigned, hereby declare that: 1. I have complied with the relevant training requirements prescribed for registration as a security service provider. 2. I am mentally sound for the purposes of rendering a security service. 3. I am not in the permanent employ of the South African Police Service, the Directorate of Special Operations, the National Intelligence Agency, the South African Secret Service, the South African Defence Force or the Department of Correctional Services. 4. I am not currently employed in the Public Service in circumstances where my registration as a security service provider may conflict with a legislative provision applicable to me. 5. The information furnished in this application as well as the content of any document submitted with this application is, to the best of my knowledge, true and correct. FULL NAME: SIGNATURE: DATE OF APPLICATION: 5

Application Fee TOTAL R160 (VAT inclusive) THE AUTHORITY WILL NOT BE HELD LIABLE FOR INCORRECT BANKING DETAILS Account holder s name:. Bank name: Bank acc: Branch code: Signature: BANKING DETAILS Private Security Industry Regulatory Authority Bank: Nedbank, Arcadia Account Number: 16333 66200 Branch Code: 163345 Ref no: Your ID number HEAD OFFICE Pretoria Johannesburg 420 Witch-Hazel Avenue, Private Bag X 817 481 Belvedere Street Ground Floor, Intec House Block B Eco Galdes 2 130 Cnr. Marshall & Eloff PRETORIA Arcadia Office Park, Street Highveld Ext 70, Centurion 0123375670 0123375500 0120030500 011-3310300 / 5530 CAPE TOWN DURBAN MTHATHA 2nd Floor, Thibault House 41 Williams Road 35 Callaway Street Thibault Square Umbilo MTHATHA Hans Strydom Avenue DURBAN 021-4252370/1/2/3 0313055622. 047-5323523 Nelspruit Polokwane PORT ELIZABETH 21 Brander Street Room 204, 2nd Floor, Parklane 1st Floor, Southern Life Bldg Building NELSPRUIT 76 Hans van Rensburg Street 84 Govan Mbeki Street 013-7524059 015-2970209 041-5851848/2100/6851 Security Industry Regulatory Authority Application Checklist Individual (RSA CITIZENS) 6

Name Date NO. REQUIREMENT REGULATION 1. Duly completed application form (SIRA 1) 2(1) 2. Payment of prescribed amounts of R160 2(2)(a) 3. Authenticated copy of first page of ID document 2(2)(b) 4. Proof of permanent residence (if not an SA resident) 2(2)(c) 5. Authenticated recent clear passport size photo of applicant 2(2)(d) 6. Clear and complete set of applicant s fingerprints 2(2)(e) 7. Clearance certificate on criminal record status of applicant if answer to question 2 on the application form is yes 2(2)(g) 8. Proof of accredited training (At least grade E must have been captured on PSIRA system) 2(2)(i) - Grade E for individual applications 3(2) - Other grade required in terms of nature of security service to be performed 3(2) - Grade B for executives, managers, directors, members, partners, trustees, administrators or persons who manage, control or supervise the rendering of a security service 3(3) 9. Clearance certificate in respect of ex-members of any official, military, security, police or intelligence force or service (if the answer to question 3 on the application form is yes ) 2(2)(h) 10. Suretyship form in respect of directors, members, partners, trustees, or administrators of a security business 2(2)(j) 11. Proof of residence (municipal bill or affidavit stating where the applicant resides) 7

Security Industry Regulatory Authority Application Checklist Individual (NON-RSA CITIZENS) Name Date NO. REQUIREMENT REGULATION 1. Application letter and testimonials if any 2(1) 2. Duly completed application form (SIRA 1) 2(1) 3. Payment of prescribed amounts of R160 2(2)(a) 4. Authenticated copy of first page of ID document and Confirmation letter of the ID obtainable from any Home Affairs office 2(2)(b) 5. Permanent residence permit / Valid asylum documents / valid refugee documents 2(2)(c) 6. Authenticated recent clear passport size photo of applicant 2(2)(d) 7. Clear and complete set of applicant s fingerprints 2(2)(e) 8. Original Police Clearance certificate on criminal record status of applicant from the country of origin (compulsory) 2(2)(g) 9. Proof of accredited training (At least grade E must have been captured on PSIRA system) 2(2)(i) - Grade E for individual applications 3(2) - Other grade required in terms of nature of security service to be performed 3(2) - Grade B for executives, managers, directors, members, partners, trustees, administrators or persons who manage, control or supervise the rendering of a security service 3(3) 10. Clearance certificate in respect of ex-members of any official, military, security, police or intelligence force or service (if the answer to question 3 on the application form is yes ) 2(2)(h) 11. Suretyship form in respect of directors, members, partners, trustees, or administrators of a security business 2(2)(j) 12. Proof of residence (municipal bill or affidavit stating where the applicant resides) 8

SOUTH AFRICAN POLICE SERVICE ENQUIRY SUID-AFRIKAANSE POLISIE DIENS NAVRAAG TO BE COMPLETED IN BLOCK LETTERS Surname: Van:... Name: Naam:. ID Number: ID mmer:.. Sex: Geslag:. M F Date of birth: Geboortedatum: MOET IN BLOKLETTERS VOLTOOI WORD Address: Adres: VA-number: FA-nommer:. CR number: KR nommer:. SAP CRC ref. no. SAP KRS verw. Nr.. FP class VA-klas SA Citizen: Y N SA Burger: If not, please state citizenship: Indien nie, vermeld burgerskap:... RIGHT HAND Thumb Duim Forefinger Wysvinger Middle finger Middelvinger Ring finger Ringvinger Little finger Pinkie 1 2 3 4 5 vou REGTERHAND LEFT HAND fold 6 7 8 9 10 vou LINKERHAND fold LEFT HAND LINKER HAND RIGHT HAND REGTERHAND Plain impression of the four fingers taken simultaneously Reason for enquiry Aard van navraag LEFT THUMB LINKERDUIM Vlakafdrukke van die vier vingers tegelyk geneem Private Security Industry Regulatory Authority. Application for registration as a Security Service Provider Aansoek om registrasie as Sekuriteitsverskaffer Have you ever been convicted of any offence? If so, state place, date and sentence. Is u ooit weens n oortreding skuldig bevind? Indien so, vermeld plek, datum en vonnis. RIGHT THUMB REGTERDUIM Applicant s signature Handtekening van applicant Fingerprints taken by: SAP station: Date: Vingerafdrukke geneem deur: SAP-stasie:. Datum:... Checked: Nagesien:.. (Station Commander/Stasiebevelvoerder) 9

Private Security Industry Regulatory Authority Private Bag X 817, Pretoria, 0001 Tel.: +27 12 003 0500 / 0501 Fax-to-email: 086 219 4359 Email.: Brenda-ann.MARAIS@psira.co.za Website.: www.psira.co.za ANNEXURE TO APPLICATION BY AN INDIVIDUAL (NATURAL PERSON) [SIRA-1] Application for registration as a security service provider in terms of the Private Security Industry Regulation Act 56 of 2001 ( the Act ) APPLICATION FOR EXEMPTION IN TERMS OF SECTION 23(6) IF THE APPLICANT HAS PREVIOUS CRIMINAL RECORD, ASYLUM SEEKERS AND NON S A CITIZENS. Important note: In terms of section 23(6) of the Private Security Industry Regulation Act 56 of 2001, despite the provisions of section 23 (1) and (2), the Authority may on good cause shown and on grounds which are not in conflict with the purpose of this Act and the objects of the Authority, register any applicant as a security service provider 1.1 Full name, Surname and ID number of the applicant: 1.2 Applicant Contact address including telephone, fax, cellphone and email address: 10

1.3 Tick the appropriate subsection/s of Section 23 that you would like to be exempted From: 1. 23 (1)(a) Green S A ID or permanent resident permit 2. 23(1)(b) Applicant must be 18 years and above 3. 23(1)(c) training certificate(s) 4. 23(1)(d) Guilty of a scheduled criminal offence within the last ten years 1. 23(1)(e) Guilty of improper conduct in terms of the Act within the last five years 2. 23(1)(f) clearance certificate if former / current member of any official military, elsewhere security, police or intelligence force or service in South Africa or 3. 23(1)(g) mentally sound 4. 23(1)(h) employed in the public service in circumstances where such registration may conflict with legislative provision applicable to the applicant 5. 23(1)(i) Registration fee 11

6. 23(1)(j) is a person referred to in subsection (5) which states that despite any provision to the contrary, a person in the permanent employ of the Service, the Directorate of special Operations, the National Intelligence Agency, the South African Secret Service, the South African National Defence Force or the Department of Correctional services may not be registered as a security service provider whilst so employed 12

In the event of a criminal record in terms of Section 23(1)(d), pending criminal prosecution(s) or investigations provide a detailed motivation, which must include the nature and facts of the offence, the place, date, and sentence and/or any other information you might think relevant for an EXEMPTION in terms of section 23 (6)Type of offence Date committed Conviction Tell us what happened. Eg. If it was theft I stole the... 1.4 Provide a detailed motivation, which must include your personal circumstances, why you do not or cannot comply with the provisions of section 23, the type of work you intend to pursue in the industry, whether you have worked in a similar industry. 13

2. Attach any other documents or representations you would like to make, so that an informed decision can be taken when considering your exemption in terms of section 23(6) Signature : Date : End. 14