No. 41970   59 STAATSKOERANT, 12 OKTOBER 2018 L0000000001 B7. EMPLOYMENT RECORD - THE MOST RECENT EMPLOYER Employer Physical address Street Town/Village Province Postal address Province Postal code Telephone no., incl. area code Cell phone no. Contact person’s name Period of employment (YYYYMMDD) From To Nature of work performed B8. REFERENCE PERSON TO THE CHILD - COMPULSORY The reference to the birth is Witness to the birth Family member Legal guardian Person who raised the person Pastor/Priest Tribal authority Social worker Other, please specify ID No. Citizenship Date of birth (YYYYMMDD) Passport no./Permanent residence permit no. Surname Previous/Maiden surname Forenames in full Physical address Street Town/Village Province Postal address Province Postal code Telephone no., incl. area code Cell phone no. Registered place of birth Country of birth Since what date have you been associated with a person whose birth is required to be registered? Date Y Y Y Y M M M M M M M M M PART C C1. DETAILS OF THE PARENT/NEXT OF KIN/LEGAL GUARDIAN ID No. Citizenship Date of birth (YYYYMMDD) Y Y Y Y M M M M M M M M M D D Surname Previous/Maiden surname Forenames in full Place of birth Country of birth Current contact address Street Town/Village Province Telephone no., incl. area code Cell phone no. E-mail address Postal address Province Relationship to the child: Are you listed on the sexual offenders register Postal code Mother/Parent A Yes Father/Parent B No Next of kin Legal guardian If yes, specify Page 7 of 9 This gazette is also available free online at www.gpwonline.co.za Social worker D D