FORM 51: Application for Duplicate National Lottery Licence

1 Step 1

1. I (Name of Applicant)

do hereby make an application in terms of regulation 98 for a duplicate National Lottery licence.

2. Trading name of the Applicant (if the Applicant is a Company):

3. Physical Address

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Postal Address

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Telephone

Fax

Emaila valid email

4. Please provide details of original licence:

Licence No:

Date of Issue:

Place of Issue:

Date of Expiry:

5. Please indicate reasons for the 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.