Stakeholder Name

Reg.No (if applicable)

Please Select One or More:
 Non-Profit Organization
 Non-Profit Company
 Entertainment Organization
 Public Benefit Organization
 Political Organization
 Trade Union Organization
 Religious Organization
 Government Institution
 Private Entity
 Community Based Organization
 Tribal Authority Organization
 Other: (Please State Below)

Select Citizenship
 SA Citizen
 Non-citizen with permanent residence

Applicant from a rural area? *
 Yes
 No

Community Name

Province
 KwaZulu-NatalEastern CapeNorth WestEastern CapeWestern CapeLimpopoWestern CapeEastern CapeWestern CapeGautengGautengNorth WestNorth WestMpumalangaGautengKwaZulu-NatalFree StateNorthern CapeWestern CapeMpumalangaKwaZulu-NatalKwaZulu-NatalEastern CapeNorthern CapeKwaZulu-NatalFree StateFree StateLimpopoNorthern CapeEastern CapeNorth WestMpumalangaEastern CapeWestern CapeNorthern CapeEastern CapeGautengLimpopoFree StateKwaZulu-NatalKwaZulu-NatalKwaZulu-NatalKwaZulu-NatalKwaZulu-NatalLimpopoLimpopoWestern CapeGautengFree StateNorthern CapeKwaZulu-Natal

District
 Alfred Nzo DistrictAmajuba DistrictAmathole DistrictBojanala Platinum DistrictCape Winelands DistrictCapricorn DistrictCentral Karoo DistrictChris Hani DistrictDr Kenneth Kaunda DistrictDr Ruth Segomotsi Mompati DistrictEhlanzeni DistrictFezile Dabi DistrictFrances Baard DistrictGarden Route DistrictGert Sibande DistrictHarry Gwala DistrictiLembe DistrictJoe Gqabi DistrictJohn Taolo Gaetsewe DistrictKing Cetshwayo DistrictLejweleputswa DistrictMopani DistrictNamakwa DistrictNgaka Modiri Molema DistrictNkangala DistrictOR Tambo DistrictOverberg DistrictPixley Ka Seme DistrictSarah Baartman DistrictSedibeng DistrictSekhukhune DistrictThabo Mofutsanyana DistrictUgu DistrictuMgungundlovu DistrictuMkhanyakude DistrictuMzinyathi DistrictuThukela DistrictVhembe DistrictWaterberg DistrictWest Coast DistrictWest Rand DistrictXhariep DistrictZF Mgcawu DistrictZululand District

Municipality
 Buffalo City (East London – Mdantsane – Zwelitsha – King William’s Town – Bhisho)City of Cape Town (Cape Town – Milnerton – Atlantis – Bellville – Mitchells Plain – Khayelitsha – Somerset West – Simon’s Town)City of Johannesburg (Johannesburg – Soweto – Roodepoort – Lenasia – Randburg – Sandton – Midrand)City of Tshwane (Pretoria – Centurion – Soshanguve – Hammanskraal – Mamelodi – Bronkhorstspruit)Ekurhuleni (Alberton – Katlehong – Germiston – Kempton Park – Tembisa – Boksburg – Benoni – Brakpan – Springs – Daveyton – Nigel)eThekwini (Durban – uMhlanga – KwaMashu – Phoenix – oThongathi – Pinetown – Cato Ridge – Chatsworth – Umlazi – Amanzimtoti – eMkhomazi)Mangaung (Bloemfontein – Botshabelo – Thaba ‘Nchu)Nelson Mandela Bay (Port Elizabeth – iBhayi – Despatch – Uitenhage)

Ward No:

Applicant is between 16 -35?
 Yes
 No

Applicant is a Board Member/Executive Committee Member/Advisory/ Volunteer of Safe a Boy Child?
 Yes
 No

Applicant is a Government Employee?
 Yes
 No

If Yes Which Department?
 Civilian Secretariat for Police Service (CSPS)Department of Agriculture, Land Reform and Rural Development (DALRRD)Department of Basic Education (DBE)Department of Communications and Digital Technologies (DCDT)Department of Cooperative Governance (DCoG)Department of Correctional Services (DCS)Department of Defence (DoD)Department of Employment and Labour (DEL)Department of Forestry, Fisheries and the Environment (DFFE)Department of Health (DoH)Department of Higher Education and Training (DHET)Department of Home Affairs (DHA)Department of Human Settlements (DHS)Department of International Relations and Cooperation (DIRCO)Department of Justice and Constitutional Development (DoJ&CD)Department of Military Veterans (DMV)Department of Mineral Resources and Energy (DMRE)Department of Planning, Monitoring and Evaluation (DPME)Department of Police (SAPS)Department of Public Enterprises (DPE)Department of Public Service and Administration (DPSA)Department of Public Works and Infrastructure (DPWI)Department of Science, Technology and Innovation (DSI)Department of Small Business Development (DSBD)Department of Social Development (DSD)Department of Sport, Arts and Culture (DSAC)Department of Tourism (DT)Department of Trade, Industry and Competition (the dtic)Department of Traditional Affairs (DTA)Department of Transport (DOT)Department of Water and Sanitation (DWS)Department of Women, Youth and Persons with Disabilities (DWYPD)Government Communication and Information System (GCIS)Independent Police Investigative Directorate (IPID)National School of Government (NSG)National TreasuryOffice of the Chief Justice (OCJ)State Security Agency (SSA)Statistics South Africa (Stats SA)

Other Department

Applicant is a Social Service Worker?
 Yes
 No

Identity Number *

Initials *

Full names *

Surname *

Age *

Gender *
 Male
 Female
 Other

Physical Address *

Trade or Profession *
 Employed
 Self-employed
 Unemployed
 Student

Contact No: Home/Cell Phone *

Email Address

Marital Status *
 Single
 Married
 Divorced
 Widow
 Widower

Particulars of next of Kin

Spouse / Partner

Cell phone

Do you have a Criminal Record?
 YES
 NO

DECLARATION BY THE APPLICANT

*1. I am aware that it is an offence to make a false statement and that all the information in this application is true and correct. *2. I understand that the membership of the institution of not politically driven and it’s of a social service institution. *3. I give consent to the social service institution to make communication to me as a member via email and or direct calls or any other means of communication. *4. I attach hereto a copy of my Identification Book or Identification card.

Attach copy Of Proof Of Residence