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MIE Background Screening Form

This document is a personal credential verification and indemnity declaration form. It contains sections for company details, the types of checks required, personal information of the candidate, qualification information, and an indemnity declaration. The indemnity declaration authorizes a verification company to obtain information about the candidate's credentials from various sources and suppliers, and to furnish this information to the company for employment purposes. It also indemnifies the verification company against any liability from providing this information.

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Tumi Matlou
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456 views1 page

MIE Background Screening Form

This document is a personal credential verification and indemnity declaration form. It contains sections for company details, the types of checks required, personal information of the candidate, qualification information, and an indemnity declaration. The indemnity declaration authorizes a verification company to obtain information about the candidate's credentials from various sources and suppliers, and to furnish this information to the company for employment purposes. It also indemnifies the verification company against any liability from providing this information.

Uploaded by

Tumi Matlou
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Personal Credential Verification

Permission and Indemnity Declaration

(A) COMPANY DETAILS (“The Company”) To be completed by Company Agent – PLEASE PRINT

Company Name: Email:


Branch Name: Phone:
Agent Name: Fax:
(B) CHECKS REQUIRED
Criminal Check: Afis MIE ID Validation Drivers License
Qualification Fraud Listing Professional Drivers Permit
Employment Reference Sequestration Permanent Residence
Passport Citizenship Retail Employment History
Directorship Search Deed Search CCMA Awards

Bureau Comprehensive TransUnion Experian NOTE:


Bureau Notices TransUnion Experian Reason Code Required! Please select a
Bureau ID Verification TransUnion Reason Code from the list below

** 1. Employment in a position that requires trust and honesty and entails the handling of cash or finances…………….
2. Verifying educational qualifications and employment ................................................... ………………………………
3. Fraud detection and fraud prevention services ............................................................. ………………………………
(C) PERSONAL INFORMATION

Surname:

Full First Names:

Maiden Name: Date of Birth:

Primary ID No:

2nd ID / Passport:

Res. Address:

Code:
(D) QUALIFICATION INFORMATION To be completed by Candidate – PLEASE PRINT
(1) (2) (3)

Qualification:

Institution/School:

City / Address:

Date Obtained:

Student No:

Certificate No:

Exam No:

(E) INDEMNITY DECLARATION To be completed by Candidate – SIGN and DATE


I hereby authorize the Company’s duly authorized verification agent, Managed Integrity Evaluation (Pty) Ltd (“MIE”), to forward any personal
information as well as any information that I have provided in support of my application to verification information suppliers acting on behalf of MIE
(including but not limited to the South African Police Services/Ideco, the Government of the RSA, and any educational, training, credit bureau and
fraud prevention organizations) for the purpose of verifying my personal credentials and records.
Authorized credential verification types include, but are not limited to, educational qualifications, professional membership, employment history,
employment references, consumer credit, criminal record, drivers’ license and fraud prevention checks.
I authorize MIE’s verification information suppliers to furnish information regarding my credentials, whether claimed or not, to MIE and the Company.
I unconditionally indemnify MIE and its verification information suppliers against any liability that may result from furnishing information in this
regard.
I understand that it is a condition of MIE’s verification information suppliers that this information is furnished by them solely for the purposes of
my proposed / continuation of employment via the offices of the Company and that any information that is furnished to the Company and MIE
will be disclosed to me before a decision is made on my continued employment or application for employment. Furthermore, I authorize MIE to
host my fingerprints and, upon request and with my consent, to release criminal results to other organisations.
/ /
CANDIDATE SIGNATURE DD MM CCYY
As the enquiring Agent of the Company, and in the case that this form instructs MIE to provide consumer credit information, I hereby state that I
understand the provisions of the National Credit Act (34 of 2005), section 70(2)(g), and the Regulations made in terms of the Act, section 18(4)
and (5).

/ /
AGENT SIGNATURE DD MM CCYY
All signatories to this document agree that MIE will NOT be held liable for the content, factual correctness or accuracy of any Supplier Data supplied
to MIE for the Company by MIE’s suppliers. The Company and the Candidate hereby indemnifies and holds MIE harmless against any loss
arising from neglect or damage in procuring, communicating or failing to communicate information to the Company

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