ETDPSETA Moderator Re-registration Form

ETDPSETA Moderator Re-registration FormPURPOSEThis form is for the use of moderators who were previously registered with ETDPSETA andtheir registration period has expired and they are re-applying for registration withETDPSETA.*Assessor Number:APPLICANTS DETAILSTitle:Full name as per ID:Surname:Initials:RSA ID Number:Alternative ID Number:Nationality:CONTACT DETAILSFax No:Cell Phone No:Email Address:Preferred Communication Method:BUSINESS ADDRESSP.O Box:City:Postal Code:Province:N.B If the above scope is different from your original scope of registration, youmust complete the extension of scope application.Doc No 13/3/2/2 Version: 02/2011 1

*DECLARATION OF AUTHENTICITY BY APPLICANTThis section needs to be completed by the moderatorI hereby declare that the information supplied is true and correct._________________Signature(Moderator Candidate)___________________Date*DECLARATION OF AUTHENTICITY BY PROVIDER REPRESETATIVE:This section should be completed by the provider representative. (if linked to a provider)I hereby declare that the information supplied by the applicant is true and correct._____________________Name & Surname(Provider Representative)_____________________Date*mandatory fields(For office use only)Moderator TypeModerator Registration NumberRe-registration Start DateRe-registration End DateDoc No 13/3/2/2 Version: 02/2011 2