FORM 41: Application for a Testing Agent Licence

[]
1 Step 1
FORM 41: Application for a Testing Agent Licence
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
0 /
Postal address
0 /
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:
0 /
6. Is the agent registered with the Authority as a testing agent of gambling machines or devices: YES/NO
0 /
7. Please provide details of the Applicant’s experience in the testing of gambling machines or devices:
0 /
8. 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);
Upload
2. Proof of registration as a testing agent;
Upload
3. Valid tax clearance certificate; and
Upload
4. Proof of shareholding.
Upload
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.
Previous
Next