Applicant’s Information

Title:	Choose an item.
First name:	Click or tap here to enter text.
Middle names:	Click or tap here to enter text.
Surname:	Click or tap here to enter text.
Address 1:	Click or tap here to enter text.
Address 2:	Click or tap here to enter text.
City/Town:	Click or tap here to enter text.
Province:	Choose an item.
Postal code:	Click or tap here to enter text.
Work Telephone:	Click or tap here to enter text.
Cell:	Click or tap here to enter text.
Email:	Click or tap here to enter text.
Date of Birth:	Click or tap to enter a date.
ID Number	Click or tap here to enter text.
Gender:
Ethnicity:	Choose an item.
Disability:

Education and Work Experience

Highest education qualification:	Choose an item.
Field of study:	Click or tap here to enter text.
Years of experience:	Click or tap here to enter text.
Employment Status:	Choose an item.

Please provide further information on your work and business experience:

(Include details of previous entrepreneurial ventures)

Personal Record

Have you ever been found guilty of a criminal offense
Have you ever been summoned or had judgements taken against you?

Company Information

Company/Institution Name:	Click or tap here to enter text.
Company’s registration number:	Click or tap here to enter text.
Company’s tax number: (provide a tax clearance certificate)	Click or tap here to enter text.
Company’s VAT registration number:	Click or tap here to enter text.
BBBEE level:	Choose an item.
Type of business:	Choose an item.

Are you an SMME? (Fewer than 200 employees, an annual turnover of less than R64 million, capital assets of less than R23 million, direct managerial involvement by owners)
How many people are directly employed by your company?	Click or tap here to enter text.
How long has your company been in business?	Click or tap here to enter text.
Have you ever been involved in the transfer and/or commercialisation of technology?
Have you or your company developed any intellectual property?
Do you or your company possess any intellectual property?
What form of technology transfer would interest you and your company?	Choose an item.

Please provide further information on your company/business (1000 characters max., including spaces)

(Include details of previous entrepreneurial ventures)

Provide highlight of your or company/business’ previous involvement in the sanitation sector (if any) (1000 characters max., including spaces)

Provide details of current alliances and partnerships (if any) (1000 characters max., including spaces)