FORM 45: Notice of Intention to Register as an Excluded Person

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1. I (Name of Applicant):

in terms of the provisions of the Act and these Regulations, do hereby notice my intention to be registered as an excluded person.

2. Physical address

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Postal address

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Telephone

Fax

Tax No.

3. State the reason(s) for the application:

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DOCUMENTS TO BE SUBMITTED WITH THIS APPLICATION

1. Two identical and recent coloured passport-size photos of person to be excluded;

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2. Certified copy of identity document (Omang or passport).

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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.