Page 1 of 31
                                                                                                                                                         Office Use
             Form No.:                                    Registration As A Professional
             APP-D1                                                Certificated Engineer
             Effective Date:
             15 March 2021
             Rev no: 1
                                                                                                                                                     Form D1.1
                                                                                                                               Ref.: 
                        NB: Please consult the Information Sheets (Sheets D1.1 & D1.2) before completing this Application.
             1. General Information:
              Surname:                                                  Title and First Names:                                                   PHOTOGRAPH
                                                                                                                                                  (Passport-type.
                                                                        Identity No:                                                               Please paste -
              Date of Birth:                                                                                                                       do not staple)
                                                                        Or Passport No.
                                                                         Country Passport:                                                         Alternatively,
                                                                                                                                                       insert
              *Race Group               Asian:             Black:       Gender           Male                 Country of normal                   electronically in
              Please tick the                                           Please tick                           residence:                         JPEG or similar
              applicable block                                          the                                                                           format
                                       Coloured:          White:        applicable      Female
                                                                        block)
                                                                         
              Home Address:                                          Postal Address:                              Name & Address of present 
                                                                                                                  Employer:
              Tel. No. (Home):                                       Title of Position held:                      Tel. No. (Employer):  
              Tel. No. (Work): (include area codes)                                                               Fax No.: (include area codes)
              Cell No.:                                                                                           E-mail:
              E-mail:
             *Completion of this section is necessary to accurately reflect equity statistics in terms of Government Policy. Please cross applicable blocks.
             2.       Qualifications:     (All qualifications at tertiary level other than Government Certificates of 
                      Competency.)
                                                                                                                                       Copies            Office
                        Educational Institution                            Qualification                     Year obtained            attached             use
                                 It is the responsibility of the user to ensure that the latest version is used. The latest version is published on ECSA website.
                                                                    QM-TEM-001 Rev 0 – ECSA Policy/Procedure
         Page 2 of 31
         Form No.:                   Registration As A Professional
         APP-D1                            Certificated Engineer
         Effective Date:
         15 March 2021
         Rev no: 1
          NB:    Kindly initial this page in the presence of a Commissioner of Oaths / Justice of Peace.
                                                         Commissioner Of Oaths/
          Applicant:  ………………………….                        Justice Of Peace:    ………………………………………
                                                                                                        /...
                     It is the responsibility of the user to ensure that the latest version is used. The latest version is published on ECSA website.
                                           QM-TEM-001 Rev 0 – ECSA Policy/Procedure
            Page 3 of 31
            Form No.:                                  Registration As A Professional
            APP-D1                                             Certificated Engineer
            Effective Date:
            15 March 2021
            Rev no: 1
                                                                                                                                             Form D1.2
            3.      Government Certificates of Competency:  (Complete for each certificate held)
                Type of Certificate          Date       Certificate   Office             Type of Certificate               Date      Certificate   Office
                                            Issued       Number        Use                                                Issued      Number        Use
            MH&S Act – Electrical                                              MH&S Act – Manager (Metal)
            MH&S Act – Mechanical                                              MH&S Act – Managers (Coal)
            OH& S Act – Electrical                                             MS Act – Ch Eng Off : Forgn 
                                                                               Going
            OH&S Act – Mechanical                                              xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx            xxxxxx      xxxxxxx
                                                                               x
            4.      Legal Appointments:   (Spanning a minimum of 1 Year NON-ACTING)
                Act/Regulation under which Appointed                 Date from               Date to              Employer              Copy attached
            5.      Previous / Current Registration or Application Details:  (eg. Candidate Engineering Technologist,
                       Professional Engineering Technician,  etc.)
                             Type                                Category                               Number                              Date
              Previous Registration:
              Current Registration:
              Previous Application:
            6. Membership of Voluntary Associations recognised in terms of Act No 46 of 2000 (or other):
                      (If more space is needed, please supply information separately.)
                Name of Association / Institute / Society                              Membership grade and date of admission
            7. Application Fee:   (Fees are available on ECSA website or here.)
                      Please note:      Only credit card payments or proof of electronic payment.   Do not pay with cash or with 
                                        postal orders.
                               It is the responsibility of the user to ensure that the latest version is used. The latest version is published on ECSA website.
                                                                QM-TEM-001 Rev 0 – ECSA Policy/Procedure
           Page 4 of 31
           Form No.:                              Registration As A Professional
           APP-D1                                         Certificated Engineer
           Effective Date:
           15 March 2021
           Rev no: 1
             My Application fee of R                                  (cheque) is transferred electronically.
            8. Referees: 
             (1)                                                             (2)
             E-mail:                                                         E-mail:
             Tel No:                                                         Tel No:
             NB:    Kindly initial this page in the presence of a Commissioner of Oaths / Justice of Peace.
                                                                               Commissioner of Oaths/
             Applicant:  ………………………….                                           Justice Of Peace:……………………..
                                                                      Office Use Only
             Application fee:    R _______________________
             Received by:        _________________________            Date:   ____________________
                                                                                                                      (Council’s stamp)
            Note: Voluntary Associations List is available on the ECSA or here  
                             It is the responsibility of the user to ensure that the latest version is used. The latest version is published on ECSA website.
                                                           QM-TEM-001 Rev 0 – ECSA Policy/Procedure