FORM 41: Application for a Testing Agent Licence

1 Step 1

1. I (Name of Applicant):

in terms of the provisions of the Act and these Regulations, do hereby make an application to register as a testing agent of gambling machines or devices and confirm being aware of and understanding the provisions of the Act and these Regulations.

2. Physical address

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Postal address

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Telephone

Fax

Tax No.

3. 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)

4. 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)

5. Have any of the directors of the Applicant been convicted of a criminal offence or been involved in any way with personal or company insolvency in any country: YES/NO If yes, please give details of the nature, date and the sentence imposed:

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6. Is the agent registered with the Authority as a testing agent of gambling machines or devices: YES/NO

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7. Please provide details of the Applicant’s experience in the testing of gambling machines or devices:

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8. Please provide the names and contact details of professional referees:

Name of of reference	contact number	Postal Address	email address
				×
				×

(2)

DOCUMENTS TO BE SUBMITTED WITH THIS APPLICATION

1. Certificates of incorporation and registration (if the Applicant is a company);

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2. Proof of registration as a testing agent;

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3. Valid tax clearance certificate; and

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4. 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.