(18/2001/2)         81/ 
          J693 
 
IFOMU 2 
 
UKUFAKWA KWESIMANGALO NGOKUYALA KWESIGABA 20 SOMTHETHO WOKUQHUBEKISA UKULINGANA NOKUVIMBELA UBANDLULULO OLUNGALUNGILE KA 2000(UMTHETHO ONGUNOMBOLO 4 KA 2000) 
 [uMthethonkambiso 6 (1)] 
 
Qaphela: 1.Imibhalosifungo eyenziwe ngabanye abantu noma amanye amaphepha okufakazela             udaba kufanele kuxhunyelwe kuleli fomu. 
2Uyakhunjuzwa ukuthi inkantolo yokulingana ingadlulisela loludaba kwenye inkundla noma isigungu.  Uma udaba lubuyiselwa emuva enkantolo yokulingana umabhalane wenkantolo uyokwazisa galokho. 
 
 [Uma isikhala esinikeziwe singanele, thumela imininingwane uyinamathisele kule fomu, usayine wonke awakhasi.] 
 
kuNgxenye A:  IMINININGWANE KAMMANGALI (kumele kugcwaliswe uma ufaka isimangalo wena ngokwakho) 
 

 
Isibongo: 
  
 
Amagama ngokuphelele: 
  
 
Inombolo kamazisi/Usuku lokuzalwa: 
  
  
  
  
  
  
  
  
  
  
  
  
  
       /           / 
 
Ikheli lalapho uhlala khona: 
  
 
 
 
 
 
                                                          Ikhodi (                  ) 
 
Inombolo yocingo:yalapho uhlala khona 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Inombolo ye selula: 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Ikheli lwasemsebenzini: 
  
 
 
 
 
 
                                                          Ikhodi (                 ) 
 
Inombolo yocingo:lasemsebenzini 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Inombolo yesikhahlamezi (fax): 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Ikheli lalapho uhlala khona (lapho kuzothunyelwa khona amaphepha ecala): 
  
 
 
 
 
 
                                                    Ikhodi  (                        ) 
 
Indlela okhetha ukuthi lithunyelwe ngayo lelifomu kulabo abathintekayo kuloludaba: 
 Iposi elibhalisiwe 
(Registered) 
 Iposilesishwezisi 
(E-mail) 
 Isikhahlamezi 
(fax) 
 Isikhozi senkantolo 
 Umabhalane wenkantolo 
 
Imininingwane yokuxhumana (Bheka ngenhla) 
  
 
Ikheli lokuposa ngesishwezisi (e-mail) 
  
 
Eminye imininingwane engasiza (njengesimo sezimali, ukuba khona kwezinqola zokuhamba, isimo somnotho nenhlalakahle, ukuthi uzodingeka yini umuntu ozohumusha/ozotolika noma akhona amanye amalungiselelo enziwe njengokulungisela izihlalo/izinqola zabakhubazekile)angasiza uMquli wodaba ukwenza izinqumo ezithaphelene nenkundla okufanele kwedluliselwe kuyo udaba : 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
kuNgxenye B: IMINININGWANE YOMUNTU OMANGALA INHLANGANO EGAMENI LOMUNYE UMUNTU NGOKUYALA KWESIGABA 20(1)(b)-(f) UMUNTU/UMGWAMANDA (kufanele kuxhunyelwe ubufakazi bokuthi lowo muntu unalo igunya lokumangala ngokuyala kwesigaba 20(1)(b)-(f) 
 
 
 
Isibongo: 
  
 
Amagama ngokuphelele: 
  
 
Inombolo kamazisi/Usuku lokuzalwa: 
  
  
  
  
  
  
  
  
  
  
  
  
  
       /           / 
 
Igunya lalowo muntu lokumangala ngokuyala kwesigaba 20 (1) (b) - (f): 
  
 
Inombolo yokubhaliswa yaleyo nhlangano: 
  
 
Ikheli laseKhaya: 
  
 
 
 
 
 
                                                                       Ikhodi (                  ) 
 
Inombolo yocingo:lwalopho uhlalakhona 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Inombolo yeselula: 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Ikheli lasemsebenzini: 
  
 
 
 
 
 
                                                                          Ikhodi (                 ) 
 
Inombolo yocingo: 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Inombolo yesikhahlamezi(fax): 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Ikheli lalapho uhlala khona (lapho kuzothunyelwa khona amaphepha odaba): 
  
 
 
 
 
 
                                                                  Ikhodi (                        ) 
 
Indlela okhetha ukuba lithunyelwe ngayo lelifomu: 
 Iposi elibhalisiwe 
 Iposilesishwezisi
(E-mail) 
 Isikhahlamezi 
(fax) 
 
 
 Isikhonzi senkantolo 
 Umabhalane wenkantolo 
 
Imininingwane yokuxhumana (Bheka ngenhla) 
  
 
Ikheli lokuposa ngesishwezisi (e-mail) 
  
 
Amagama namakheli abantu okufakwa isimangalo egameni labo:  
  
 
 
 
 
 
                                                                Ikhodi (                        ) 
 

  
 
 
kuNgxenye C:  IMINININGWANE KAMMANGALELWA/ABAMANGALELWA (lemininigwane elandelayo kufanele inikezwe  ngalowo nalowo mmangalelwa. 
 


Igama lomuntu noma inhlangano emangalelwayo: 
  
 
 
 
 
 
 
 
Inombolo kamazisi/usuku lokuzalwa: 
  
  
  
  
  
  
  
  
  
  
  
  
  
       /           / 
 
Ikheli lasekhaya (uma likhona):lalapho ulala khona 
  
 
 
 
 
 
                                                                      Ikhodi (                        ) 
 
Inombolo yocingo:lalapho uhlala khona 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Inombolo yeselula: 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Ikheli lasemsebenzini/ikheli lalapho isebenzela khona: 
  
 
 
  
 
 
 
                                                                   Inombolo yePosi (                        ) 
 
Inombolo yocingo:lwasemsebenzini 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Inombolo yesikhahlamezi (fax): 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Indlela okhetha ukuba lithunyelwe ngayo lelifomu: 
 Iposi elibhalisiwe 
 Lokuposa ngekhomputha 
 yefekisi 
 Izinkhonzi senkantolo 
 Umabhalane wenkantolo 
 
Imininingwane yokuxhumana (bheka ngehla) 
  
 
Ikheli lapho uhlala khona (lapho kuzothunyelwa khona amaphepha odaba): 
  
 
 
 
 
 
                                                                      Ikhodi (                        ) 
 
Ikheli lokuposa ngesishwezisi: (e-mail) 
  
 

 
kuNgxenye D:  IMININIGWANE YOMUNTU OZOMELA UMMANGALI 
 
 
 
Igama nesibongo somuntu ozokumela ummangali (omele ummangali): 
  
 
 
 
Inombolo kamazisi/usuku lokuzalwa: 
  
  
  
  
  
  
  
  
  
  
  
  
  
       /           / 
 
Ikheli lokuposa lalowo omele ummangali: 
  
 
 
 
 
 
                                                                   Ikhodi (                        ) 
 
Inombolo yocingo:yalapho ehlala khona 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Inombolo yeselula: 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Inombolo yesikhahlamezi (fax):  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
Ikheli lokuposa ngesishwezisi (e-mail): 
  
 

 
kuNgxenye E:  IMININIGWANE YESIMANGALO NESINXEPHEZELO ESIFUNWAYO 
 

 
 Uhlobo lwesikhalo: (uyacelwa ukuba unikeze imininingwane ephelele, usuku okwenzeka ngalo isehlakalo (izehlakalo) kanye nemininigwane yabo bonke labo okungenzeka babe ngofakazi.  
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
Kukuphathe kanjani lokhu? 
  
 
 
 
 
 
 
 
Izincwadi: Ngakubezikhona yini izincwadi noma amaphepha angafakazela isikhalo sakho (isibonelo, isilipho (incwadiyeholo)sokukhokhela impahla, okuphathelene nakho, ukuqoshwa kwezinkulumo (record). (Uma kukhona kuxhumele lapha): 
  
 
 
 
 
 
 
 
Isinxephezelo osifunayo: ( Sitshele ukuthi ufuna sizo luni.Inkantolo ingakhipa isinqumo sesikhashana, noma inqume ukuba kukhokhwe inhlawulo, noma inqume ukuba ummangalelwa axolise ngokungenambandela noma isiphi esinye isinqumo.) 
  
 
 
 
 
 
 
 
 
 

 
kuNgxenye F:  IMINININGWANE YEZINHLANGANO/NEZIZINDA OWAKE WACELA KUZO USIZO NGAPHAMBILINI 
 

 
Imininingwane wfzinhlangano nezizinda awake wacela usizo kuzo ngaphambili mayelana nesikhalo: 
 
  
 
 
 
 
 
 
 
Izimpendulo noma usizo olutholakale kulezo okukhulunywa:ngazo ngasenhla. 
  
 
 
 
 
 
 
 

 
 
 
 
 
  
Kushicililwe e .ngalolusuku lomhlaka..Ngenyanga ka ku 20. 
 
 
 
 
Shicilelwe  uMmangali/omele iqulu labantu/isigungu/inhlangano 
 
 
 
  
  
kuNgxenye G:  UMBHALOSIFUNGO 
 

 
Ngiyaqinisa ukuthi ngaphambi kokumfungisa/ukusho iqiniso, ngimbuze lemibuzo elandelayo lona othathe isifungo ngase ngibhala izimpendulo zakhe phambi kwakhe ekhona: 
 
(1)  Uyakwazi futhi uyakuqonda okuqukethwe kulesisimemezolo esibhaliwe? 
      Impendulo:. 
(2)  Uyaphikisana yini nokuthatha isifungo/ngokufunga njengoba kumisiwe? 
       Impendulo: 
(3)  Ngabe isifungo esigciniwe usithatha njengesikubophayo kunembeza wakho na? 
        Impendulo:. 
 
Ngiyaqinisa ukuthi lona othatha isifungo uvumile ukuthi uyakwazi futhi uyakuqonda okuqukethwe yilesi simemezelo esibhaliwe.  Lona othatha isifungo usho lamazwi alandelayo:  ngiyafunga ukuthi lokhu okuqukethwe yilesi simemezelo esibhaliwe kuyiqiniso, inkosi ingisize/ Ngiqinisile ngiqinisile ngithi lokhu okuqukethwe yilesi simemezelo esibhaliwe kuyiqiniso.  Lona othatha isifungo usayinde/wenze uphawu phambi kwami ngikhona. 
 
 
 
Umthathisisifungo 
 
 
Amagama nesibongo ngokuphelele 
(Bhala ngezinhlamvu ezinkulu) 
 
 
Umsebenzi owenzayo (Isikhundla).Isikhundla osiphethe ezweni aseNingizimu Afrika 
 
Ikheli lasemsebenzini... 
Ikhodi 
(Bhala ikheli lomgwaqo) 
 
Usuku:..Indawo 
 


 

