FORM 1

APPENDIX A

APPLICATION BY A FORMER MEMBER OF THE AGENCY FOR CONSENT TO DISCLOSE CLASSIFIED INFORMATION

Application in terms of section 27 of the Act, read with Chapter XXIV

A former member of the Agency may apply to the Director-General to consider an application for consent to disclose classified information. The former member must complete this form and send it to the Director-General:

Complete this form in full. If you need more space to answer the questions then complete your answers on another sheet of paper and attach it to this form.

1.

Personal information

1.1

Name

1.2

Employee number

1.3

Address

1.4

Tel number (h)

1.5

Tel number (w)

1.6

Cell number

1.7

Fax number

2.

Employment history with the Agency

2.1

Name of employer

2.2

Directorate/Division/Unit

2.3

Occupational group

2.4

Highest post level attained

2.5

Name of immediate supervisor

2.6

Date of commencement of employment

2.7

Date of termination of employment

3.

Nature of classified information

3.1

What classified information do you want to disclose?

3.2

Why do you want to disclose this classified information?

3.3

For what purpose will this information be used?

3.4

Who will receive this information?

3.5

How do you intend to disclose the information?

4.

Further details

Is there any other information you wish to draw to the Review Board's attention?

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