SOUTHERN AFRICAN EMERGENCY SERVICES INSTITUTE NPC. FORM: ACC 5 (Accreditation Application Form-2018) Valid from 1 October September 2018

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1 SOUTHERN AFRICAN EMERGENCY SERVICES INSTITUTE NPC Registration. 2014/162285/08 Contact Details: Phone: Fax Fax: Website: Addresses:. 295 Jorissen Street Monument KRUGERSDORP, 1739 PO Box 613, KRUGERSDORP, 1740 APPLICATION Certification of Qualifications: All Accredited Courses Purpose: The purpose of this procedure is to authenticate your results and verify information supplied in support of your application and issue the appropriate international certificate if you qualify. Procedure: Students must submit the original OR certified copies of the prescribed documentation as contained in Section A20-Certification Pre-requisites of the Institutes Accreditation Policy. * Copies must be clear and legible. Should all documents not be supplied or legible the Institute will not be held liable for any delays in the certification process. * The decision of the Quality Assurance Working Group and SAESI is final. SURNAME.. FORM: ACC 5 (Accreditation Application Form-2018) Valid from 1 October September 2018 First Name(s)... ID Nr. Contact Nr.. Postal Address... (Where Certificates will be sent) Employer I hereby confirm that the information is true and that I will accept the decision of the Quality Assurance Working Group and SAESI with regards to my application. Applicant Signature.... Date Membership Nr. (If applicable): Control Officer Signature A. Applicants must submit the following requirements for certificate accreditation: 1. Completed ACC 5 Application Form 2. Certified Copy of ID and/or PASSPORT document 3. Certified Copy of Individual Statement of Results OR Outcomes letter of RPL 4. Certified Copy of Proof of Valid Medical Qualification i.e. HPCSA registration (BAA) OR First Aid Level 3 as Minimum requirement for FF1 / HA / FF2 / HO 5. Proof of Payment MUST ACCOMPANY application 6. Certified Copy of Senior Certificate/Matric (t Results letter) 7. CFO Letter confirming employment/portfolio of Evidence where applicable (See Page 3) NOTE: IN ADDITION TO THE ABOVE: The following documentation from the training provider is a prerequisite for a complete application. certificates will be approved without ALL required documentation 8. Training Provider - Course Final Results 9. Training Provider - Course Moderators Report 10. Moderators Report with proof of External Moderation (Where applicable) B. FOR OFFICE USE

2 A: LEVEL OF APPLICATION (PLEASE TICK ( ) RELEVANT) Hazmat Awareness NFPA 472 Hazmat Operations NFPA 472 Hazmat Technician NFPA 472 Fire Fighter 1 NFPA 1001 Fire Fighter 2 NFPA 1001 Driver & Operator: Pumper NFPA 1002 Driver & Operator: Aerial NFPA 1002 Airport Fire Fighter NFPA 1003 Technical Rescuer NFPA 1006 Confined Space Rescue 1 NFPA 1006 Confined Space Rescue 2 NFPA 1006 Rope Rescue 1 NFPA 1006 Rope Rescue 2 NFPA 1006 Structural Collapse 1 NFPA 1006 Structural Collapse 2 NFPA 1006 Swift Water Rescue 1 NFPA 1006 Swift Water Rescue 2 NFPA 1006 Trench Rescue 1 NFPA 1006 Trench Rescue 2 NFPA 1006 Vehicle & Machinery Rescue 1 NFPA 1006 Vehicle & Machinery Rescue 2 NFPA 1006 Wilderness Rescue 1 NFPA 1006 Wilderness Rescue 2 NFPA 1006 Fire Officer 1 NFPA 1021 Fire Officer 2 NFPA 1021 Fire Investigator NFPA 1033 Fire & Life Safety Educator 1 NFPA 1035 Fire & Life Safety Educator 2 NFPA 1035 Public Information Officer NFPA 1035 Fire Instructor 1 NFPA 1041 Fire Instructor 2 NFPA 1041 Wildland Fire Fighter 1 NFPA 1051 Wildland Fire Fighter 2 NFPA 1051 Wildland Fire Officer 1 NFPA 1051 Wildland Fire Officer 2 NFPA 1051 Interior Industrial Fire Brigade Member NFPA 1081 Advanced Exterior Industrial Fire Brigade Member NFPA 1081 Industrial Fire Brigade Leader NFPA 1081 Incipient Industrial Fire Brigade Member NFPA 1081 Fees and Payment 1. Certification Fee per Certificate (Seal) R The price per Certificate (Seal) is subject to a 10% (percentage) increase on an annual basis (October) until further notice. 2. Paid up SAESI Members ( in good standing) Certification Fee per Certificate (Seal) R SAESI Head Office Banking details: ABSA Cheque Account Nr º Branch Krugersdorp - Code Reference - ACC (and your id number or initials and surname) Example: ACC NOTE: Courier Fees for Certificates are NOT included in the Certificate Fee

3 CERTIFICATION PRE-REQUISITES Certification of the proficiency program shall be registered with SAESI only if all prerequisites are met. The Quality Assurance Working Group/SAESI reserves the right not to recognize and/or nullify results, that have not met the SAESI/IFSAC certification policies and or pre-requisites. Learners shall be at least eighteen years of age prior to the instruction process. (A-21.3) The minimum education requirement(s) for enrolling for all proficiency training programs will be a NQF 4 Certificate (Matric/Senior Certificate) with two South African Languages of which one should be English and preferably Mathematics and Physical Science. This rule is applicable for the Instruction Process and Certification Process from 1 January (A-21.4) REVOCATION / SUSPENSION / ANNULMENT / DENIAL OF CERTIFICTION (A-8) The Quality Assurance Working Group/SAESI may Revoke or Suspend or Annul or Deny the certification of any Training Provider or Candidate who; i. Intentionally makes any materially false statement on application(s) for certification ii. Falsifies training records or signatures iii. Intentionally misrepresents or violates SAESI Accreditation Policies and Procedures iv. Intentionally violates any instructor / assessor policy and or guidelines and or instructions to dishonestly complete an assessment. PORTFOLIO OF EVIDENCE (PoE) The following portfolio of evidence (PoE) as a direct evidentiary collection of documentary proof that you comply with the minimum competence requirements for entering the instruction process and minimum certification process is detailed by the ACC Application form checklist and the Accreditation Prerequisites for each NFPA level described below, inseparable from the Quality Assurance Working Group/SAESI Accreditation Policy and Procedure. (a portfolio of evidence (PoE) is a collection of documents that you must compile to show your competence against a set of learning or other required outcomes) Succession of Levels as a prerequisite of Certification for the next level in accordance with the Accreditation Policy and Procedure is detailed below.

4 A-20 CERTIFICATION PRE-REQUISITES Certification of the proficiency program shall be registered with SAESI if all pre-requisites are met. The Quality Assurance Working Group reserves the right to not recognize and/or nullify results that have not met the SAESI/IFSAC certification policies and or pre-requisites. A-20.1 Hazmat Awareness - NFPA 472 Letter of results for Hazmat Awareness (NFPA 472) course attended, reflecting the the learner. A-20.2 Hazmat Operations - NFPA 472 Letter of results for Hazmat Operations (NFPA 472) course attended, reflecting the SAESI / IFSAC Hazmat Awareness certificate the learner. A-20.3 Hazmat Technician - NFPA 472 SAESI / IFSAC Firefighter 2 certificate or Advanced Exterior Industrial Fire Brigade Member certificate or Interior Structural Fire Brigade Member certificate SAESI / IFSAC Hazmat Operations certificate Letter of results for Hazmat Technician (NFPA 472) course attended, reflecting the Course Registration Officer and a certified copy to the respective Training Centre, and not A-20.4 Fire Fighter 1- NFPA 1001 Letter of results Firefighter I (NFPA 1001) course attended, reflecting the registered course number Letter of results for Hazmat Awareness (NFPA 472) reflecting Proof of valid BAA certification (current registration with HPCSA) or valid First Aid Level 3 Certification (done within the last three years).

5 A-20.5 Fire Fighter 2 - NFPA 1001 SAESI / IFSAC Firefighter 1 certificate Letter of results for Firefighter 2 (NFPA 1001) course attended, reflecting the registered course number Letter of results Hazmat Operations (NFPA 472) reflecting Proof of valid BAA certification (current registration with HPCSA) or valid First Aid Level 3 Certification (done within the last three years) Original certified copy of national identity document. Original Moderator s report must be submitted by the Moderator to SAESI Head Office, the. A-20.6 Driver & Operator Pumper - NFPA 1002 SAESI / IFSAC Firefighter 1 certificate or Advanced Exterior Industrial Fire Brigade Member certificate or Interior Structural Fire Brigade Member certificate Letter of results for Driver & Operator Pumper (NFPA 1002) course attended, reflecting the A-20.7 Driver & Operator Aerial - NFPA 1002 SAESI / IFSAC Firefighter 1 certificate or Advanced Exterior Industrial Fire Brigade Member certificate or Interior Structural Fire Brigade Member certificate Letter of results for Driver & Operator Aerial (NFPA 1002) course attended, reflecting the Prescribed Forms (ACC 5) Proof of payment Original certified copy of national identity document. Original Moderator s report must be submitted by the Moderator to SAESI Head Office, the A-20.8 Airport Fire Fighter - NFPA 1003 SAESI / IFSAC Hazmat Operations certificate SAESI / IFSAC Firefighter 2 certificate Proof of valid BAA certification (current registration with HPCSA) or valid First Aid Level 3 Certification (done within the last three years) Letter of results for Airport Fire Fighter (NFPA 1003) course attended, reflecting the

6 A-20.9 Technical Rescuer - NFPA 1006 SAESI / IFSAC Hazmat Awareness certificate Proof of valid BAA certification (current registration with HPCSA) Letter of results for Technical Rescuer (NFPA 1006) course attended, reflecting the A Confined Space Rescue 1 - NFPA 1006 SAESI / IFSAC Technical Rescuer (NFPA 1006, Chapter 5) certificate Letter of results for Confined Space Rescue 1 (NFPA 1006) course attended, reflecting the A Confined Space Rescue 2 - NFPA 1006 SAESI / IFSAC Confined Space Rescue 1 certificate Letter of results for Confined Space Rescue 2 (NFPA 1006) course attended, reflecting the A Rope Rescue 1 - NFPA 1006 SAESI / IFSAC Technical Rescuer (NFPA 1006, Chapter 5) certificate Letter of results for Rope Rescue 1 (NFPA 1006) course attended, reflecting the registered course number

7 A Rope Rescue 2 - NFPA 1006 SAESI / IFSAC Rope Rescue 1 certificate Letter of results for Rope Rescue 2 (NFPA 1006) course attended, reflecting the A Structural Collapse 1 - NFPA 1006 SAESI / IFSAC Technical Rescuer (NFPA 1006, Chapter 5) certificate Letter of results for Structural Collapse 1 (NFPA 1006) course attended, reflecting the A Structural Collapse 2 - NFPA 1006 SAESI / IFSAC Structural Collapse 1 certificate Letter of results for Structural Collapse 2 (NFPA 1006) course attended, reflecting the A Swift Water Rescue 1 - NFPA 1006 SAESI / IFSAC Technical Rescuer (NFPA 1006, Chapter 5) certificate Letter of results for Swift Water Rescue 1 (NFPA 1006) course attended, reflecting the

8 A Swift Water Rescue 2 - NFPA 1006 SAESI / IFSAC Swift Water Rescue 1 certificate SAESI / IFSAC Rope Rescue 1certificate SAESI / IFSAC Rope Rescue 2certificate Letter of results for Swift Water Rescue 2 (NFPA 1006) course attended, reflecting the A Trench Rescue 1 - NFPA 1006 SAESI / IFSAC Technical Rescuer (NFPA 1006, Chapter 5) certificate Letter of results for Trench Rescue 1 (NFPA 1006) course attended, reflecting the Original Moderator s report must be submitted by the Moderator to SAESI Head Office, the A Trench Rescue 2 - NFPA 1006 SAESI / IFSAC Trench Rescue 1 certificate Letter of results for Trench Rescue 2 (NFPA 1006) course attended, reflecting the registered course number A Vehicle & Machinery Rescue 1 - NFPA 1006 SAESI / IFSAC Technical Rescuer (NFPA 1006, Chapter 5) certificate Letter of results for Vehicle & Machinery Rescue 1 (NFPA 1006) course attended, reflecting the

9 A Vehicle & Machinery Rescue 2 - NFPA 1006 SAESI / IFSAC Vehicle & Machinery Rescue 1 certificate Letter of results for Vehicle & Machinery Rescue 2 (NFPA 1006) course attended, reflecting the A Wilderness Rescue 1 - NFPA 1006 SAESI / IFSAC Technical Rescuer (NFPA 1006, Chapter 5) certificate Letter of results for Wilderness Rescue 1 (NFPA 1006) course attended, reflecting the Original certified copy of national identity document. Original Moderator s report must be submitted by the Moderator to SAESI Head Office, the A Wilderness Rescue 2 - NFPA 1006 SAESI / IFSAC Wilderness Rescue 1 certificate Letter of results for Wilderness Rescue 2 (NFPA 1006) course attended, reflecting the A Fire Officer 1 - NFPA 1021 SAESI / IFSAC Firefighter 2 certificate SAESI / IFSAC Fire Instructor 1 certificate Letter of results for Fire Officer 1 (NFPA 1021) course attended, reflecting the registered course number

10 A Fire Officer 2 - NFPA 1021 SAESI / IFSAC Fire Officer 1 certificate Letter of results for Fire Officer 2 (NFPA 1021 ) course attended, reflecting the A Fire Investigator - NFPA 1033 SAESI / IFSAC Hazmat Awareness certificate Letter of results for Fire Investigator (NFPA 1033) course attended, reflecting the A Fire & Life Safety Educator 1 - NFPA 1035 Letter of results for Fire & Life Safety Educator 1 (NFPA 1035) course attended, reflecting the. A Fire & Life Safety Educator 2 - NFPA 1035 SAESI / IFSAC Fire & Life Safety Educator 1 certificate Letter of results for Fire & Life Safety Educator 2 (NFPA 1035) course attended, reflecting the.

11 A Public Information Officer - NFPA 1035 SAESI / IFSAC Firefighter 2 certificate or Advanced Exterior Industrial Fire Brigade Member certificate or Interior Structural Fire Brigade Member certificate Letter of results for Public Information Officer (NFPA 1035) course attended, reflecting the. A Fire Instructor 1 - NFPA 1041 SAESI / IFSAC Firefighter 2 Certificate or Advanced Exterior Industrial Fire Brigade Member certificate or Interior Structural Fire Brigade Member certificate IFSAC Hazmat Operations certificate Letter of results for Fire Instructor 1 (NFPA 1041) course attended, reflecting the A portfolio of evidence indicating relevant experience in the roles and responsibilities of an instructor (applicable from January 2013) A portfolio of evidence indicating relevant operational experience in a Fire and Rescue Service of at least 24 months after certification as per NFPA 1001 Chapter 6 and NFPA 472 Chapter 6.. A Fire Instructor 2 - NFPA 1041 SAESI / IFSAC Fire Instructor 1 certificate Letter of results for Fire Instructor 2 (NFPA 1041) course attended, reflecting the A portfolio of evidence indicating relevant experience of at least 24 months in the roles and responsibilities of a Fire Instructor 1

A-20.32 Wildland Fire Fighter 1 - NFPA 1051 SAESI / IFSAC Hazmat Awareness certificate Proof of valid BAA certification (current registration with HPCSA) or valid First Aid Level III Certification

12 A Wildland Fire Fighter 1 - NFPA 1051 SAESI / IFSAC Hazmat Awareness certificate Proof of valid BAA certification (current registration with HPCSA) or valid First Aid Level III Certification (done within the last three years) Letter of results for Wildland Fire Fighter 1 (NFPA 1051) course attended, reflecting the A Wildland Fire Fighter 2 - NFPA 1051 SAESI / IFSAC Wildland Fire Fighter 1 certificate Letter of results for Wildland Fire Fighter 2 (NFPA 1051) course attended, reflecting the A Wildland Fire Officer 1 - NFPA 1051 SAESI / IFSAC Wildland Fire Fighter 2 certificate Letter of results for Wildland Fire Officer 1 (NFPA 1051) course attended, reflecting the A Wildland Fire Officer 2 - NFPA 1051 SAESI / IFSAC Wildland Fire Officer 1 certificate Letter of results for Wildland Fire Officer 2 (NFPA 1051) course attended, reflecting the

13 A Interior Industrial Fire Brigade Member - NFPA 1081 SAESI / IFSAC Advanced Exterior Industrial Fire Brigade Member certificate SAESI / IFSAC Hazmat Operations certificate Letter of results for Interior Industrial Fire Brigade Member (NFPA 1081) course attended, reflecting the A Advanced Exterior Industrial Fire Brigade Member - NFPA 1081 SAESI / IFSAC Incipient Industrial Fire Brigade Member certificate Proof of valid BAA certification (current registration with HPCSA) or valid First Aid Level III Certification (done within the last three years) SAESI / IFSAC Hazmat Awareness certificate Letter of results for Advanced Exterior Industrial Fire Brigade Member (NFPA 1081) course attended, reflecting the A Industrial Fire Brigade Leader - NFPA 1081 SAESI / IFSAC Interior Industrial Fire Brigade Member certificate Letter of results for Industrial Fire Brigade Leader (NFPA 1081) course attended, reflecting the A Incipient Industrial Fire Brigade Member - NFPA 1081 Letter of results for Incipient Industrial Fire Brigade Member (NFPA 1081) course attended, reflecting the

SOUTHERN AFRICAN EMERGENCY SERVICES INSTITUTE NPC Registration No. 2014/162285/08. Interior Industrial Fire Brigade Member- NFPA 1081, 2007

SOUTHERN AFRICAN EMERGENCY SERVICES INSTITUTE NPC Registration No. 2014/162285/08 Contact Details: Phone: 011-660 5672 Fax2Email: 086 544 0008 Fax: 011 660 1887 Email: info@saesi.com Website: www.saesi.com