FORM 40: Application for Registration as Seller, Lessor, Distributor, e.t.c of Gambling Machines or Devices

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FORM 40: Application for Registration as Seller, Lessor, Distributor, e.t.c of Gambling Machines or Devices
1. I (Name of Applicant):

in terms of the provisions of the Act and these Regulations, make an application to register as a seller, lessor, distributor, marketer, maintenance provider repairer or 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 ShareholderNo. of SharesPostal AddressId or Passport No.:
×
×
(2)
4. 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)
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. Provide details of experience of the Applicant:
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7. Please provide the names and contact details of professional referees:
Name of of referencecontact numberPostal Addressemail 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. Valid tax clearance certificate;
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3. 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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