FORM 37: Application for Transfer of Licence to own, possess etc, gambling machine or device

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FORM 37: Application for Transfer of Licence to own, possess etc, gambling machine or device
1. I (Name of Applicant):
do hereby in terms of the provisions of the Act and these Regulations make an application for the transfer of the licence to own, possess etc, gambling machine or device issued to me, being licence no:
to

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 or establishment where the gambling machine or device is going to be kept:
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3. Postal address of the premises or establishment where the gambling machine or device is going to be 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 ShareholderNo. of SharesPostal AddressId or Passport No.:
×
×
(2)
6. Please provide details of the directors of the Applicant (if the Applicant is a company):
Name of DirectorNo. of SharesPostal AddressId or Passport No.:
×
×
(2)
7. Please provide details of the shareholders of the transferee (if the transferee is a company):
Name of ShareholderNo. of SharesPostal AddressId or Passport No.:
×
×
(2)
8. Please provide details of the directors of the Transferee (if the transferee is a company):
Name of DirectorNo. of SharesPostal AddressId or Passport No.:
×
×
(2)
9. 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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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.
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