FORM 39: Application for Lease or Transfer of Possession of a Gambling Machine or Device

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1. I (Name of Applicant):

do hereby, in terms of the provisions of the Act and these Regulations, make an application for the lease/transfer of the gambling machine(s) or device(s) held by me, under licence no:

and confirm being aware of and understanding the provisions of the Act and these Regulations, insofar, as they pertain to this application.

2. Physical address of the premises where the gambling machine(s) or device(s) is/are kept:

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3. Postal address of the premises where the gambling machine(s) or device(s) is/are kept:

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4. Telephone

Fax

5. Please provide details of the shareholders of the Applicant (if the Applicant is a company): (use separate sheet if necessary)

Name of Shareholder	No. of Shares	Postal Address	Id or Passport No.:
				×
				×

(2)

6. Please provide details of the directors of the Applicant (if the Applicant is a company):

Name of Director	No. of Shares	Postal Address	Id or Passport No.:
				×
				×

(2)

7. Please provide the contact details of the person or company to which ownership orpossession of the machine(s) or device(s) is/are being transferred:

Telephone of Transferee

Fax of Transferee

Postal address of transferee

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Email of Transferee

8. Please provide details of the shareholders of the lessee/transferee (if the transferee is a company):

Name of Shareholder	No. of Shares	Postal Address	Id or Passport No.:
				×
				×

(2)

9. Please provide details of the directors of the lessee/Transferee (if the transferee is a company):

Name of Director	No. of Shares	Postal Address	Id or Passport No.:
				×
				×

(2)

10. Please provide a full description of the impact of the transfer of the licence on the business of the licensee, with specific reference to the following (separate sheet to be used): (a) Management structure; (b) Financial operations of the licensee; and (c) Operations of the licensee.

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11. Please provide the details of the gambling machine(s) or device(s) that is/are being transferred below:

Name and description of the machine or device	Serial no.	Purpose of the machine or device	Date of purchase of the machine or device	Date of transfer of the machine or device
					×
					×

(2)

12. Please state the reasons for the transfer of ownership of the machine(s) or devices(s):

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DOCUMENTS TO BE SUBMITTED WITH THIS APPLICATION

1. Certified copies of share certificates of the transferee (if the transferee is a company);

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2. Proof of directorship (certified copies) of the transferee(if the transferee is a company) ;

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3. Title deed, lease or sublease agreement of premises to be utilised for the gambling establishment (certified copy);

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4. Certified copies of the agreements governing the transfer of the licence;

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5. Copies of audited financial statements of the transferee;

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6. Certified copy of a tax clearance certificate of the transferee;

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7. Proof of shareholding.

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I certify that the information supplied on this application form (please print name clearly) is true and correct. I understand that failure to provide true and correct information will result in the failure of this application.