1.

Title ..................................................................................................................................................................................

2.

Surname ...........................................................................................................................................................................

3.

Forenames .......................................................................................................................................................................

4.

Sex ...................................................................................................................................................................................

5.

Date of birth .....................................................................................................................................................................

6.

Identity number ...............................................................................................................................................................

7.

Nationality  .......................................................................................................................................................................

8.

Residential address ..........................................................................................................................................................

.........................................................................................................................................................................................

.....................................................................................................................

Postal code .............................................

9.

Telephone number  ..........................................................................................................................................................

10.

Business address .............................................................................................................................................................

........................................................................................................................................................................................

....................................................................................................................

Postal code ............................................

11.

Telephone number .........................................................................................................................................................

12.

Postal address .................................................................................................................................................................

.......................................................................................................................................................................................

....................................................................................................................

Postal code ...........................................

13.

From which date will you be able to act as sheriff:

.........................................................................................................................................................................................

14.

Were your previously in possession of a fidelity fund certificate? If so, give details:

..........................................................................................................................................................................................

..........................................................................................................................................................................................

..........................................................................................................................................................................................

15.

Have you at any time been dismissed from a position of trust by reason of improper conduct involving a breach of such trust?  If so, give details:

..........................................................................................................................................................................................

..........................................................................................................................................................................................

..........................................................................................................................................................................................

16.

Have you at any time been convicted of any offence involving dishonesty, or of any other offence for which a sentence of imprisonment without the option of a fine was imposed?  If so, give details:

..........................................................................................................................................................................................

..........................................................................................................................................................................................

..........................................................................................................................................................................................

17.

Have you ever been declared insolvent?  If so, give details"

..........................................................................................................................................................................................

..........................................................................................................................................................................................

..........................................................................................................................................................................................

18.

Were you previously the holder of a fidelity fund certificate which was cancelled under sections 34(1) or 49 of the Sheriffs Act, 1986?  If so, give details:

..........................................................................................................................................................................................

..........................................................................................................................................................................................

..........................................................................................................................................................................................

19.

Have you passed the course of the South African Instituted for Sheriffs?  If so, attach a certified copy of certificate hereto:

..........................................................................................................................................................................................

20.

Have you been exempted by the board or the Minister from passing the Board's examination?  If so, give details:

..........................................................................................................................................................................................

..........................................................................................................................................................................................

..........................................................................................................................................................................................

21.

Have you passed the examination of the Board for Sheriffs?  If so, state on which date the examination was passed:

..........................................................................................................................................................................................

22.

Has the Board ever cancelled a fidelity fund certificate of a sheriff of whom you were an employee at the time of such cancellation?  If so, give details:

..........................................................................................................................................................................................

..........................................................................................................................................................................................

23.

Have you already paid over to the Fidelity Fund of the Board the interest accrued to your trust account for the previous financial year?

..........................................................................................................................................................................................

..........................................................................................................................................................................................

I declare hereby under oath/affirmation that the above particulars given by me are in all respects true and correct.

......................................................................................

Sheriff

...........................................................

Date

Duly executed and sworn/affirmed before me at the place and on the date herein mentioned by the deponent, who acknowledges that he/she—

..............................................................

Place

..............................................................

Date

.............................................................

Commissioner of Oaths/Justice of the Peace