CD(SA) Registration Form. This registration must be accompanied with the non-refundable registration fee.

Transcription

1 CD(SA) Registration Form This registration must be accompanied with the non-refundable registration fee. The Institute of Directors in Southern Africa (IoDSA)

2 Please complete the application form. Submit the application form (including the signed CD(SA) Candidate Declaration on page 7) to The CD(SA) Secretariat, IoDSA, Sandton. The application must be accompanied by: - Full curriculum vitae - Certified copies of qualifications - Certified copy of ID - Proposer Letter - Supporter Letter Proof of payment (referenced appropriately) must also accompany the application in order to ensure it is processed timeously. PERSONAL DETAILS (compulsory) Titles (Mr/ Mrs/Ms/) Surname First Names Known as Name of Company (where applicable) VAT No. (of company) Home Address Date of Birth Nationality Code ID No. Alternative ID No. Postal Address Alternative ID Type IoDSA Membership No. Code Male Province Female African Indian / Asian Coloured White Phone No. Fax No. Cell No. Page 2

3 Required for SAQA reporting. South African Socio-Economic Status Employed Unemployed Residential Status Dual: Permanent Resident English None Sight Hearing Communication Afrikaans siswati TshiVenda sesotho Disability Status Physical Intellectual Emotional Multiple disabilities Home Language isixhosa sepedi xitsonga Unspecified isindebele setswana isizulu Highest School Qualification Highest Qualification Achieved Grade 12 / Matric Qualifications currently enrolled for Page 3

4 EXPERIENCE AS AN EXECUTIVE OR NON-EXECUTIVE DIRECTOR Only indicate the experience you have had as a director of the board of the organisation, as listed below. Type of company (tick the appropriate block) Name of Company / Organisation Large Listed Small To Medium Listed National Govt Dept Provincial Govt Dept Local Govt Dept Large Private Company Medium Private Company Small Private Company Large Trust Small To Medium Trust NPO with members Charitable NPO Executive or Non-Exec Period Served (in years) Please insert additional rows if required Page 4

5 EXPERIENCE ON BOARD COMMITTEES Only complete this table if you served on a board committee Type of board committee (tick the appropriate block) Name of Company / Organisation Company Secretary Audit and/or Risk Committee Remuneration Committee Social & Ethics Committee Transformation Committee Audit Committee Member or Chairman Period Served (in years) Please insert additional rows if required Page 5

6 OTHER ACTIVITIES RELATED TO CORPORATE GOVERNANCE** Only complete this section if you have been involved in other activities outside of directorship that related to corporate governance. Type of company (tick the appropriate block) of activity Member of international committee Chairperson of international committee Chairperson of local committee Member of local committee Advisor / lecturer / facilitator / consultant - national Advisor / lecturer / facilitator / consultant - international Member or Chairman Period Served (in years) Please insert additional rows if required **These activities need to be related to the field of corporate governance and include participating in the King Committee at the IoDSA or serving as chairman of an international working group that might input into a South African regulator like the FSB. Page 6

7 CD(SA) Applicant Declaration This director s declaration forms part of the application for registration for Chartered Director (SA) and needs to be completed in full by the applicant. Personal details 1 Surname of Director 2 Any former surname 3 First name 4 Identity number 5 Physical address Code: 6 Postal address Code: 7 Telephone number (business) 8 address Qualifications and experience 9. Are you a director, or alternate director of any other company that is publicly listed or traded, or a partner in any partnership? If so, state the name of any such company or partnership, the nature of business where this is not indicated in the title, and the date you became a director or partner. Company name Capacity** Nature of business Date of appointment ** Director, alternate director or partner 10. Have you ever been disqualified by a court from acting as a director of a company, or from acting in the management or conduct of the affairs of any company as described in section 7.B of the Listings Requirements 1? If so, give full particulars. Name of company 1 Relevant extract of Section 7.B of the Listings Requirements included as Appendix A. Page 7

8 11. Have you ever been convicted of any offence resulting from dishonesty, fraud, theft, forgery, perjury, misrepresentation or embezzlement? If yes, provide details. Offence 12. Has any company been put into liquidation or been placed under business rescue proceedings or had an administrator or other executor appointed during the period when you were (or within the preceding 12 months had been) one of its directors, or alternate directors or equivalent position? If yes, provide details. Name of company 13. Have you ever been adjudged bankrupt or sequestrated in any jurisdiction? If yes, provide details. Charge / Pronouncement 14. Have you at any time been a party to a scheme of arrangement or made any other form of compromise with your creditors? If yes, provide details. Activity 15. Have you ever been found guilty in disciplinary proceedings, by an employer or regulatory body, due to dishonest activities? If yes, provide de- tails. Activity Page 8

9 16. Have you ever been barred from entry into any profession or occupation? If yes, provide details. Profession 17. Have you at any time or has a company of which you were a director or alternate director or officer at the time of the offence, been convicted in any jurisdiction of any criminal offence, or an offence under legislation relating to the Companies Act. All such convictions must be disclosed even though they may now be spent convictions. Conviction 18. Have you ever been removed from an office of trust, on the grounds of misconduct, involving dishonesty? If so, give full particulars. Activity 19. Has any court granted an order declaring you to be delinquent or placed you under probation in terms of Section 162 of the Companies Act and/or Section 47 of the Close Corporations Act, 1984 (Act No. 69 of 1984)? If so, give full particulars. Activity 21. In terms of the additional requirements, please also answer the following questions by ticking the appropriate block: Question Yes No Are you an un-emancipated minor, or under similar legal disability Are you an un-rehabilitated insolvent Have you been prohibited in terms of any public regulation from being a director of the company Page 9

10 20. Is there anything from your past that would bring you or the CD(SA) designation under scrutiny or disrepute? Provide a brief description in the space provided. I... (name of applicant) declare that to the best of my knowledge and belief (having taken all reasonable care to ensure that such is the case) the answers to all the above questions are true, and I hereby give my authority to the IoDSA to disclose any of the foregoing particulars as the IoDSA may, in its absolute discretion, think fit. I also acknowledge that... (name of applicant), agree to be bound by and to comply with the CD(SA) Governing Body s requirements in terms of gaining Chartered Director (SA) status, as amended from time to time, and, in my capacity as a director, I undertake and agree to discharge my duties in ensuring such compliance whilst I am a designee. I further acknowledge that certain requirements contained in the IoDSA s Chartered Director (SA) requirements, as amended from time to time, affect me directly as a designee and I under- take to be bound by and to comply with all such requirements whilst I am a designee. Signature Date Page 10

11 Appendix A: Extract from JSE Listing Requirements Directors and management 7.B.1 The full name and, if relevant, any former name, business address and function in the group of each of the following persons and an indication of the principal activities performed by them, including any activities performed outside the group where these are significant with respect to the group: (a) directors of the issuer and its major subsidiaries; (b) partners with unlimited liability, in the case of a limited partnership with share capital; (c) founders, if the issuer has been established for fewer than five years; and (d) in the case of the applicant and its major subsidiaries, any manager who is relevant to establishing that the requirements of paragraph 4.8 (directors) have been met. Typically, this will include any members of management forming part of the applicant s, or applicant s material subsidiaries, executive and/or management committees responsible for the day to day running of the applicant group s business. 7.B.2 In the case of each person described in paragraph 7.B.1 (a) and (d), details of that person s relevant management expertise and experience (see paragraph 4.8) and the following information: (a) full names; (b) occupation and/or function, including whether in an executive or non executive capacity, for example; non executive chairman, executive chairman, chief executive officer, managing director, financial director, other relevant executive and non executive director functions/status and the executive functions of all managers specified; (c) business address; (d) nationality; (e) the names of all companies and partnerships of which such person has been a director or partner at any time in the previous five years, indicating whether or not the individual is still a director or partner. It is not necessary to list all the subsidiaries of a company of which the person is also director; (f) details of any bankruptcies, insolvencies or individual voluntary compromise arrangements of such person; (g) details of any business rescue plans and/or resolution proposed by any entity to commence business rescue proceedings, application having been made for any entity to begin business rescue proceedings, notices having been delivered in terms of Section 129(7) of the Act, receiverships, compulsory liquidations, creditors voluntary liquidations, administrations, company voluntary arrangements or any compromise or arrangement with creditors generally or any class of creditors of any company; where such person is or was a director, with an executive function within such company at the time of, or within the 12 months preceding, any such event(s); (h) details of any compulsory liquidations, administrations or partnership voluntary arrangements of any partnerships where such person is or was a partner at the time of or within the 12 months preceding such event(s); (i) details of receiverships of any asset(s) of such person or of a partnership of which the person is or was a partner at the time of, or within the 12 months preceding, such event; (j) details of any public criticisms of such person by statutory or regulatory authorities, including recognised professional bodies, and whether such person has ever been disqualified by a court from acting as a director of a company or from acting in the management or conduct of the affairs of any company; (k) details of any offence involving dishonesty committed by such person; (l) details regarding such person s removal from an office of trust, on the grounds of misconduct and involving dishonesty; and (m) details of any court order declaring such person delinquent or placing him under probation in terms of Section 162 of the Act and/or Section 47 of the Close Corporations Act, 1984 (Act No. 69 of 1984) or disqualifying him to act as a director in terms of Section 219 of the Companies Act, 1973 (Act No. 61 of 1973). Page 11

12 Incomplete applications will be returned to the sender. This will slow down the processing of the application and cause delays. Please ensure that the application and supporting documents are complete. Applications must be accompanied by a proof of payment for the non-refundable registration fee. Please see the CD(SA) Handbook for current fee. Payments are made to. IoDSA - First National Bank Branch: Parktown Code: Account: Reference: CDSA + membership no. Please contact the CD(SA) secretariat at micheles@iodsa.co.za to request an invoice for the Application for Registration of the CD(SA). Include the following information in your request: Name of person the invoice should be made out to Company name VAT no. Billing address Receipt of your application will be acknowledged by means of an . The application will then be processed and the outcome thereof communicated to you via . Page 12