Compulsory Assessment Fee R95.00 This assessment fee MUST be paid in addition to the following registration fees:

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1 Please print and fill in. COUNCIL FOR COUNSELLORS IN SOUTH AFRICA RAAD VIR BERADERS IN SUID-AFRIKA APPLICATION FORM / REGISTRASIE VORM P.O. Box / Posbus Sinoville 0129 Tel: (office hours only, no sms function) Fax: / E mail : c4council@yahoo.com (NB. No faxed nor ed applications are acceptable. Please post original to postal address) Date: Datum:... PROF / DR / MR / MRS / MISS PROF / DR / MNR / MEV / MEJ SURNAME: FIRST NAMES: VOLLE VOORNAME: NATIONALITY: NASIONALITEIT: IDENTITY NUMBER: *Please attach certified copy IDENTITEITS NOMMER: Category applied for / Kategorie waarvoor aansoek gedoen word Please select one / Merk asb. een X Compulsory Assessment Fee R95.00 This assessment fee MUST be paid in addition to the following registration fees: CATEGORY REQUIREMENTS COST 1. Specialist Counsellor Masters / PhD Degree R annually 2. Counsellor B / Honours Degree R annually 3. Institutional Counsellor Certificate / Diploma R annually 4. Counsellor in Training In Training R annually Assessment Fee COMPULSORY R Bank Details: Council for Counsellors First National Bank Kolonnade ( ) Acc: (Cheque)

2 PERSONAL PARTICULARS RESIDENTIAL ADDRESS / WOONADRES POSTAL ADDRESS / POSBUS ADRES TELEPHONE NUMBERS / TELEFOONNOMMERS HOME : WORK: HUIS : WERK: CELL: FAX : SEL : FAKS: LANGUAGE PREFERANCE / TAAL VOORKEUR AFR ENG EMPLOYER / WERKGEWER POSITION / POSBENAMING QUALIFICATIONS ATTACH CERTIFIED COPIES / HEG GEWAARMERKTE KOPIEë AAN QUALIFICATIONS YEAR - FROM YEAR - TO UNIVERSITY/INSTUTION KWALIFIKASIES JAAR - VAN JAAR - TOT UNIVERSITEIT/INSTANSIE

3 OTHER APPROPRIATE TRAINING / ANDER TOEPASLIKE OPLEIDING (ATTACH SEPARATE PAGE IF NEEDED / HEG APARTE FOLIO AAN INDIEN NODIG) COURSE / KURSUS DATE / DATUM PRESENTED BY / AANGEBIED DEUR OTHER APPROPRIATE EXPERIENCE / ANDER TOEPASLIKE ONDERVINDING (ATTACH SEPARATE PAGE IF NEEDED / HEG APARTE FOLIO AAN INDIEN NODIG) EXPERIENCE : TIME FROM TIME TO INSTITUTION ONDERVINDING : TYD VAN TYD TOT INSTELLING PROFESSIONAL REGISTRATION / ANDER PROFESSIONELE REGISTRASIE NAME OF INSTITUTE / NAAM VAN INSTELLING DATE / DATUM FROM /VAN TO/ TOT OFFENSES / OORTREDINGS SUSPENSIONS FROM INSTITUTIONS / SKORSINGS VAN ENIGE INSTANSIES INSTITUTION / INSTANSIE REASON / REDE DATE / DATUM CRIMINAL OFFENSES / KRIMINELE OORTREDINGS DESCRIPTION / BESKRYWING SENTENCE / VONNIS DATE / DATUM DECLARATIONS / VERKLARINGS VERKLARING Ek het sonder voorbehoud die waarheid in die antwoorde in hierdie aansoek verstrek. In die geval van n valse verklaring behou die Raad hom die reg voor op skrapping sonder kennisgewing of vergoeding. DECLARATION I have stated the truth in the replies made in this application, without reservation. In the event of a false declaration, the Board reserves the right to remove my particulars without notice or compensation. SIGNATURE / HANDTEKENING DATE / DATUM

4 RECOMMENDATION (PLEASE DUPLICATE AND HAND COPY TO REFERENT) WE REQUIRE TWO RECOMMENDATIONS FROM SIGNIFICANT PEOPLE SUCH AS COMMUNITY LEADER OR EDUCATORS The following Pages must be completed by: Your teacher/educator/trainer OR A regular client AND One character reference (minister, headmaster, significant person) etc. (name of applicant, in full) has reached the desired level of competency to be permitted to apply for registration with your organisation. I (names of referent/teacher in full) confirms his/her competency by reporting as follows: The applicant is a person with ethical integrity. Is competent in the area of health care/counselling in which he/she specializes is emphatic towards clients/patients. respects and honours his/her teachers/superiors. subscribes to keeping information/records confidential respects the rules and regulations/legislation and constitution of the South African Government and the CCSA. does not suffer from any drug or alcohol addictions. does not have a criminal record. Details of Referent: Name Signature Date Address Code Telephone No (W) (H) (Cell)

5 OFFICIAL USE / KANTOORGEBRUIK REGISTRATION CATEGORY / REGISTRASIE KATEGORIE NO/NR PAYMENT RECEIVED / BETALING ONTVANG DATE / DATUM REF NR / VERW NO CERTIFICATE POSTED / SERTIFIKAAT VERSEND DATE / DATUM REF NR / VERW NO SIGNATURE OF REGISTRATION : HANDTEKENING VAN REGISTRASIE: DATE : DATUM:... Please note that this formis valid for 2016/2017 period only.