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					                                Room No RV052, Floor 1                 Room No RV052, Floor 1                  Kamer Nr RV052, Vloer 1
                                Goodwood Fire Station                  Lokucima Umlilo Lase i-Goodwood         Goodwood Brandweerstasie
                                c/o Frans Conradie & Hugo Street       c/o Frans Conradie & Hugo Street        h/v Frans Conradie & Hugo Straat
                                Goodwood, Cape Town                    Goodwood, Cape Town                     Goodwood, Cape Town
                                P O Box 298, Cape Town 8000            P O Box 298, Cape Town 8000             Posbus 298, Kaapstad 8000
                                Tel: 021 597 5000                      Umnxeba: 021 597 5000                   Tel: 021 597 5000
                                Fax: 021 597 5010                      Ifeksi: 021 597 5010                    Faks: 021 597 5010
                                E-mail: DisasterRiskManagement.Centre@capetown.gov.za
                                Website: http://www.capetown.gov.za/disaster
                                Ref: HQ31/3/2/1/1/ws
                                Filename: N:\Disaster Risk Management Templates\CoCTDisManVolunteerApplicationForm.doc




DISASTER RISK MANAGEMENT CENTRE

                     APPLICATION FOR APPOINTMENT AS A DISASTER
                       MANAGEMENT VOLUNTEER CORPS MEMBER


                                 1. PERSONAL PARTICULARS
                                (Please complete in block letters)


1.1   SURNAME              ………………………………………………………………………………………..

1.2   FIRST NAMES:         ………………………………………………………………………………………..

1.3   SEX/GENDER:          ……………………                           IDENTITY NUMBER:                    ……………………………....

1.4   RESIDENTIAL ADDRESS                                     POSTAL ADDRESS
                                                              (Only if different from residential address)

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

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

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

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

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

      Postal Code: ………………………………                               Postal Code: …………………………………………...

1.5   TELEPHONE NUMBER:              HOME                     …………………………………………………………...

                                     WORK                     …………………………………………………………...

                                     CELL                     …………………………………………………………..

1.6   QUALIFICATIONS       ………………………………………………………………………………………..

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

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

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

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

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

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




           THIS CITY WORKS FOR YOU    ESI SIXEKO SISEBENZELA WENA                      HIERDIE STAD WERK VIR JOU
                                                       2

1.7      NATURE OF SERVICE TO WHICH                   THE       APPLICANT       IS     PREPARED              TO       COMMIT
         HIMSELF/HERSELF (PLEASE TICK)


             First Aid                           Firefighting                              Traffic Control


        Communications                         Care & Comfort                                     Other


            Logistics /                         Maintenance
                                                                                                  Other
          Administration                         (Specify


1.8      ARE YOU A MEMBER OF THE UNDER-MENTIONED? IF YES, TICK WHERE APPLICABLE

                                                                                          South African
       South African Police                                                              National Defence
                                               Police Reserve
            Services                                                                          Force –
                                                                                           Permanent
      South African National
                                                Correctional                               Emergency
        Defence Force –
                                                 Services                               Services Reservist
      Reserves/Commandos


                                      2. EMPLOYMENT PARTICULARS
                     (To be completed by the employer) / (Please complete in block letters)


2.1      BUSINESS NAME:          ………………………………………………………………………………………..

2.2      OCCUPATION:             ………………………………………………………………………………………..

2.3      STAFF NUMBER:           ………………………………………………………………………………………..

2.4      ADDRESS:                ………………………………………………………………………………………..

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

2.5      TELEPHONE NUMBER:               WORK              …………………………………………………………..

2.6      THE ABOVE INFORMATION TO BE CERTIFIED AS CORRECT BY THE EMPLOYER (AS
         APPLICABLE)

         REMARKS BY EMPLOYER (If any):

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

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




                                       NAME OF EMPLOYER:                  ………………………………………..


                                       SIGNATURE OF EMPLOYER: ………………………………………..


                                       DATE:                              ………………………………………..




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                                                     3


                            3. CODE OF CONDUCT FOR VOLUNTEER MEMBER


The overall image of the Corps should be done of dedicated and disciplined service to the community.

A member shall accept training and deployment, as required by the Head: Disaster Risk Management
Centre, in one or more of the following sections:

       Communications
       Firefighting
       First Aid / Disaster Nursing
       Care & Comfort
       Logistics / Administration
       Traffic Control
       Maintenance / Specific Trade

The total training period not to exceed ninety six (96) hours in any year and no remuneration for training or
secondary services will be provided.

Note: It is an offence to refuse training and call upon up for service by the Head: Disaster Risk Management
Centre whilst a registered volunteer corps member.

       Refer to the “Code of Conduct For Disaster Risk Management Volunteers”, which must be
        signed by each prospective volunteer and submitted together with this application form.


                                       4. UNDERTAKING BY APPLICANT


I, the undersigned, hereby indemnify solemnly and sincerely and for as so long as I remain a member of
Disaster Risk Management Volunteer Corps of the City of Cape Town bind myself to render, to the best of
my ability; and without fear or contradiction, the services referred to in this application; and to undergo
training in connection therewith in terms of the Disaster Management Act, Act 57 of 2002; and the
regulations promulgated thereunder.

I furthermore agree to abide to the Code of Conduct of the City of Cape Town Disaster Risk Management
Volunteer Corps as indicated above.


……………………………………………                                        ……………………………………………
    Signature of Applicant                                      Date




    CONSENT BY PARENT OR GUARDIAN (ONLY TO BE COMPLETED IN THE CASE OF A MINOR)



I, the undersigned, being the legal guardian/parent of the applicant, hereby consent to the above-mentioned
undertaking.




……………………………………………                                        ……………………………………………
Name & Surname of Guardian                                      Date




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                                                    4



            5. TO BE COMPLETED BY THE DISASTER RISK MANAGEMENT CO-ORDINATOR


The applicant wishes to join the Disaster Risk Management Volunteer Corps located at (suburb):

………………………………………………………………………………………………………………………………

and has entered into and signed this undertaking before me at ……………………………………………………

on the …………………..…………………………………………………………………………………………………


after acknowledging that he/she knows, understands and agrees to the contents thereof.



..…………………………………………………………..
HEAD: DISASTER RISK MANAGEMENT CENTRE
CITY OF CAPE TOWN




                 HEALTH QUESTIONNAIRE OVERLEAF – ALSO TO BE COMPLETED




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                                            5



     HEALTH QUESTIONNAIRE FOR APPOINTMENT AS A MEMBER OF THE DISASTER RISK
       MANAGEMENT VOLUNTEER CORPS IN TERMS OF THE PROVISION MADE UNDER
          SECTION 58 OF THE DISASTER RISK MANAGEMENT ACT, ACT 57 OF 2002


                                       SECTION A


1.   SURNAME              ………………………………………………………………………………………..

2.   FIRST NAMES:         ………………………………………………………………………………………..

3.   SEX/GENDER:          ……………………              HEIGHT: ………… BODY WEIGHT: ………………

4.   IDENTITY NUMBER:     …………………………………….                         DATE OF BIRTH: …………………


                                        SECTION B
                           (Please circle the applicable answer)


1.   HAVE YOU BEEN SUCCESSFULLY VACCINATED AGAINST SMALLPOX:                               YES         NO

2.   ARE YOU SUFFERING OR HAVE EVER SUFFERED FROM:

     ANY SKIN DISEASE?                                                                     YES         NO

     ANY AFFLICTION OF THE SKELETON OR JOINTS?                                             YES         NO

     ANY AFFLICTION OF THE EYES, EARS OR NOSE?                                             YES         NO

     ANY AFFLICTION TO THE SKELETON CIRCULATORY SYSTEM?                                    YES         NO

     ANY AFFLICTION OF THE CHEST OR RESPIRATORY SYSTEM?                                    YES         NO

     ANY AFFLICTION OF THE DIGESTIVE SYSTEM?                                               YES         NO

     ANY AFFLICTION OF THE URINARY AND/OR GENITAL ORGANS?                                  YES         NO

     ANY NERVOUS AFFLICTIONS OR MENTAL ABNORMALITY?                                        YES         NO

     ANY OTHER ILLNESS?                                                                    YES         NO

     SUPPLY DETAILS (AS APPLICABLE)

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

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

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

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

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

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

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

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

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                                           6



                                       SECTION C
                          (Please circle the applicable answer)


1.   ARE YOU SUFFERING FROM ANY DEFECT OF HEARING,
     SPEECH OR SIGHT                                                                      YES         NO

2.   ARE YOU PHYSICALLY DISABLED AND DO YOU USE ARTIFICIAL LIMBS                          YES         NO

     IF SO, GIVE DETAILS OF NATURE AND SEVERITY OF THE DISABILITY

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

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

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

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

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



                                       SECTION D
                          (Please circle the applicable answer)


1.   HAVE YOU UNDERGONE ANY OPERATIONS                                                    YES         NO

     IF SO, GIVE DETAILS OF NATURE AND SEVERITY OF THE DISABILITY

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

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

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

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

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


     I DECLARE THAT THE ABOVE INFORMATION IS TRUE AND CORRECT AND THAT I HAVE
     NOT WITHHELD ANY INFORMATION REGARDING MY HEALTH




……………………………………………                              ……………………………………………
    Signature of Applicant                            Date




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                                        7



                            FOR OFFICIAL USE ONLY



ACCEPTED:          ……………………………………………………………………………………………….

REJECTED:          ……………………………………………………………………………………………….

REMARKS:           ……………………………………………………………………………………………….

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

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

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

DISASTER RISK MANAGEMENT VOLUNTEER:         ……………………………..………...

SERVICE/(S) ASSIGNED TO :

SERVICE:     ……………………..………………………….              POSITION:              ……………………………..

SERVICE:     ……………………..………………………….              POSITION:              ……………………………..

SERVICE:     ……………………..………………………….              POSITION:              ……………………………..

SERVICE:     ……………………..………………………….              POSITION:              ……………………………..

SERVICE:     ……………………..………………………….              POSITION:              ……………………………..




..…………………………………………………………..
HEAD: DISASTER RISK MANAGEMENT CENTRE
CITY OF CAPE TOWN


DATE:        …………………………………………




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posted:11/5/2011
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