Please note that the information submitted is confidential and will not be disclosed

Should you require any assistance with completing this legal document, please contact legal@hypercheck when completing this document

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* 1. Full name and surname as per Identity Document

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* 2. Date engaged

Date

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* 3. Department

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* 4. Employed or Consultant

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* 5. Are you a fulltime/part time employee of any company, organization, trust or business other than Hypercheck (Pty) Ltd? (If Yes , provide details)

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* 6. Do you earn any commission / rebate / bulk discount with any company? (If Yes , provide details)

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* 7. Are you providing any services to any competitors, supplier or related party of Hypercheck or any of its subsidiaries or sister companies? (If Yes , provide details)

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* 8. Do you have any financial or nonfinancial interest in any company trust or organization as a Director, partner or other capacity? (If Yes , provide details)

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* 9. Do you or any immediate family member have any relationship with any Hypercheck Supplier, Service provider, contractor or other (as an employee, agent, Director, or other). If yes, kindly answer the following:

1. Full name of Entity
2. Capacity /Position within Entity
3.Relation to Connected Person Within Entity
4. Detail of Services/Trade the company is involved in

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* 10. I declare the above information is accurate and complete

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