1

Identity Number

Date of birth (CCYY/MM/DD)

Surname

First names PSIRA Number of Security

Officers (if any)

Male/Female (M/F)

Certified photograph of applicant’s face (passport size)

RESIDENTIAL ADDRESS

How would you prefer to receive your post from the Authority? (Mark with an ‘X’)

Postal Code

POSTAL ADDRESS (if different to residential address)

Mail to postal address

Mail to physical address

Collect at local Authority office:

PRETORIA

DURBAN

Postal Code

CAPE TOWN

TELEPHONE NUMBERS (Code/Number)

PORT ELIZABETH

Home

Cellphone (compulsory)

PIETERSBURG

Work

NELSPRUIT

E-MAIL ADDRESS

EMPLOYMENT STATUS

Nature of current employment

NAME AND ADDRESS OF CURRENT EMPLOYER

Postal Code

Employer’s SIRA Registration No.

Employee No.

Date of commencing employment with present employer (CCYY/MM/DD)

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]

2

Indicate the nature of the security service/s performed/to be performed (mark with ‘X’)

01 GUARDING AND/OR PATROLLING:

COMMERCIAL, INDUSTRIAL OR RESIDENTIAL

02 SAFEGUARDING ASSETS IN

TRANSIT/PROVIDING SECURE TRANSPORT

03 PROVIDING CLOSE PERSONAL

PROTECTION/ BODYGUARDING

04

PROVIDING ADVICE ON THE PROTECTION OF

PERSONS OR PROPERTY, ANY

OTHER SECURITY SERVICE OR THE USE

OF SECURITY EQUIPMENT

05 PROVIDING REACTION OR

RESPONSE SERVICES

06

ENSURING SAFETY AND ORDER ON PREMISES (SPORTING,

RECREATIONAL, ENTERTAINMENT)

07

MANUFACTURING, IMPORTING, DISTRIBUTING OR

ADVERTISING OF MONITORING DEVICES

08 FUNCTIONING AS

PRIVATE INVESTIGATOR

09 PROVIDING, SECURITY TRAINING

OR INSTRUCTION

10 INSTALLING, SERVICING OR

REPAIRING SECURITY EQUIPMENT

11 PROVIDING SERVICES OF A

LOCKSMITH 12

MONITORING SIGNALS FROM ELECTRONIC

SECURITY EQUIPMENT (SECURITY CONTROL

ROOM)

13

MAKING PERSONS OR THEIR SERVICES AVAILABLE FOR

RENDERING OF A SECURITY SERVICE

14 PROVIDING SECURITY AT

SPECIAL EVENTS 15

“CAR WATCH” OR RELATED ACTIVITIES

16 OTHER (Please specify

below)

CITIZENSHIP

SOUTH AFRICAN CITIZENSHIP

VALID PERMANENT RESIDENCE PERMIT FOR SOUTH AFRICA

PERMIT NUMBER

DATE OF ISSUE

Yes No

Yes

No

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.

3

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?

Yes

No

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?

Yes

No

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?

Yes

No

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.

4

QUESTION 4

Have you ever been declared to be of unsound mind by a court of law?

Yes

No

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?

Yes

No

NAME OF INSTITUTION PERIOD OF TREATMENT FROM

TO

If “yes”, furnish particulars.

QUESTION 6

Have you ever been declared insolvent?

Yes

No

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?

Yes

No

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?

Yes

No

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?

Yes

No

NAME OF BUSINESS/TRAINING ESTABLISHMENT SIRA/SOIB REFERENCE NUMBER

DATE OF LIQUIDATION/ SEQUESTRATION/ WINDING UP

If “yes”, furnish particulars

5

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?

Yes

No

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?

Yes No If “yes”, furnish particulars.

FULL NAME OF BUSINESS BUSINESS REGISTRATION NUMBER

OWNER/DIRECTOR/MEMBER/ PARTNER/TRUSTEE/ ADMINISTRATOR

10

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: ___________________________________________

6

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

Office Park, PRETORIA Arcadia

130 Cnr. Marshall & Eloff

Street

Highveld Ext 70, Centurion 012 337 5670

012 337 5500 012 003 0500 011-331 0300 / 5530

CAPE TOWN DURBAN MTHATHA

2nd Floor, Thibault House 41 Williams Road 35 Callaway Street

Thibault Square Umbilo MTHATHA

Hans Strydom Avenue DURBAN 021-425 2370/1/2/3 031 305 5622. 047-532 3523

Nelspruit Polokwane PORT ELIZABETH

21 Brander Street Room 204, 2nd Floor, Parklane

Bldg

1st Floor, Southern Life

Building

NELSPRUIT 76 Hans van Rensburg Street 84 Govan Mbeki Street

013-752 4059 015-297 0209 041-585 1848/2100/6851

Security Industry Regulatory Authority Application Checklist – Individual (RSA CITIZENS)

7

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)

8

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)

Security Industry Regulatory Authority Application Checklist – Individual (NON-RSA CITIZENS)

9

TO BE COMPLETED IN BLOCK LETTERS

Surname: Van: …………………………………………………………………………………... Name: Naam: …………………………………………………………………………………. ID Number: ID Nommer: ………………………………………………………………………….. Sex: Geslag: ……………………………….

M F

Date of birth: Geboortedatum: SA Citizen: SA Burger: ……………………………

Y N

If not, please state citizenship: Indien nie, vermeld burgerskap: …………………………………………………...

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

Thumb Duim

Forefinger Wysvinger

Middle finger Middelvinger

Ring finger Ringvinger

Little finger Pinkie

1 fold

2 3 4 5

vou

6 fold

7 8 9 10

vou

LEFT HAND LINKER HAND

Plain impression of the four fingers taken simultaneously

RIGHT HAND

REGTERHAND

Vlakafdrukke van die vier vingers tegelyk geneem

Reason for enquiry Aard van navraag …………………………………………………………………………………………………………………………………………….

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. …………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………

…………………………………………

Applicant’s signature Handtekening van applicant

Fingerprints taken by: SAP station: Date: Vingerafdrukke geneem deur: …………………………………………………………………SAP-stasie: ………………………………. Datum: ………………………………...

Checked: Nagesien:…………………………………………………………………………………………………………………………………….. (Station Commander/Stasiebevelvoerder)

SOUTH AFRICAN POLICE SERVICE

ENQUIRY

SUID-AFRIKAANSE POLISIE DIENS

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ND

LIN

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RH

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ND

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TH

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B

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RD

UIM

RIG

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Private Security Industry Regulatory Authority

10

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:

11

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,

security, police or intelligence force or service in South Africa or

elsewhere

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

12

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

13

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.

14

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.