FORM 21: Application for Duplicate Totalisator Licence

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FORM 21: Application for Duplicate Totalisator Licence
1. I (Name of Applicant)

do hereby make an application in terms of regulation 40 for a duplicate totalisator licence.

2. Trading name of the Applicant (if the Applicant is a Company):
3. Physical Address
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4. Postal Address
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5. Telephone
Fax

6. Please provide details of original licence:

Licence No:
Date of Issue:
Place of Issue:
Date of Expiry:
7. Please indicate reasons for this application:
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DOCUMENTS TO BE SUBMITTED WITH THIS APPLICATION

1. Copy of certificate of incorporation or certification of registration (if the Applicant is a company)
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2. Copy of original licence.
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I certify that the information supplied on this application form is true and correct. I understand that failure to provide true and correct information will result in the failure of this application.
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