Statement
This form is to be filled in to create a statement by a member of the CPF team. By entering your Full Name, ID Number, Date and Signature you are creating an official statement. By signing you are acknowledging that you have submitted, read and understood the content stated in the below statement. A signed copy of the statement will be emailed to you and it will be held on a central server.
Your Information:
Please enter your name and required information as per South Africa law for an official statement to be recognised.
Your Email Address:
*
Please enter the email that a copy of this statement will be sent to.
Your Phone Number:
*
Please enter a valid phone number for you to be contacted on regarding this incident.
Your Legal Full Name:
*
First Name
Middle Name
Last Name
Your Identity Number:
*
Your Position at the CPF you are representing:
*
Please Select
Member
Patroller Captain
Patroller
Victim Support
Civilian
Other
Please enter the position you hold at the CPF you are Representing. ie Member, Patroller CPT
Your Employer's Name:
*
Please enter your Employer's Name.
Your Age:
*
Please enter your age.
Your Gender:
*
Please Select
Male
Female
This is for the purposes of creating an official statement recognised by South African Law.
Your Physical Address where you reside:
*
Street Address
Suburb
City
State / Province
Postal / Zip Code
BODY OF STATEMENT
Please write an accurate account of the incident to the best of your ability.
Description or accurate account of the incident in your own words:
*
Witnesses:
Please enter the names and contact information for each witness to the incident.
Witness 1 Full Name:
First Name
Last Name
Witness 1 Phone Number:
Please enter a valid phone number.
Witness 1 Email Address:
example@example.com
Witness 2 Full Name:
First Name
Last Name
Witness 2 Phone Number:
Please enter a valid phone number.
Witness 2 Email Address:
example@example.com
Agreements
I know and understand the contents stated herein.
*
I agree
I have no objection in taking the prescribed oath.
*
I agree
I consider the above statement binding on my conscience.
*
I agree
Signature
Your Signature:
*
Date of signing:
*
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Place of signing:
*
Enter your location when you sign the statement.
Community In Blue
Submit
Should be Empty: