FORM 12: Application for Casino Licence Available Due to Surrender, Expiration, e.t.c.

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FORM 12: Application for Casino Licence Available Due to Surrender, Expiration, e.t.c.
Name of applicant
2. Trading name of Applicant
3. Physical Address
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4. Postal Address
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5. Telephone
Fax
6. Does the Applicant currently have an existing casino licence:pick one!
If yes, indicate the locations of the existing business or businesses:
7. Please provide details of the shareholders of the Applicant (if the Applicant is a company):
Name of ShareholdersNo. shares heldAddressId or Passport No.:
×
×
(2)
8. Please provide details of the directors of the Applicant (if the Applicant is a company):
Name Of DirectorPostal AddressTelephone No.Id or Passport No.:
×
×
(2)
9. Please provide details of the Company Secretary (if the Applicant is a company):
Name of SecretariesAddressTelephone No
×
×
(2)
10. Have any of the directors or the Company Secretary named above ever been convicted of an offence or been involved in any way with personal or company insolvency in Botswana or any other country: YES/NOpick one!
If yes, please give details of the nature of the offence, date and the sentence imposed:more details
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11. Has the Applicant, any subsidiary or associated entity of the Applicant ever been, or is currently being investigated by any law enforcement authority in Botswana or any other country: YES/NOpick one!
If yes, please give details below:more details
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12. Please provide the names and addresses of the auditors of the Applicant:

Name
Physical Address
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Postal Address
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Telephone
Fax
13. Is the Applicant intending to alter the existing casino establishment which falls under the licence being applied for:pick one!
If yes please provide details of the proposed alterations:more details
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DOCUMENTS TO BE SUBMITTED WITH THIS APPLICATION

1. Certified copy of certificate of incorporation or certificate of registration (if the Applicant is a company);
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2. Certified copies of share certificates (if the Applicant is a company);
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3. Proof of directorship (certified copies)(if the Applicant is a company) ;
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4. Title deed, lease or sublease agreement of premises to be utilised for the gambling establishment (certified copy);
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5. Documentation or proof of any application by the Applicant or any of the Applicant’s associates for a gambling-related licence anywhere in the world, and the outcome of such application;
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6. Certified copy of the tax clearance certificate of the Applicant;
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7. Copies of audited financial statements of the Applicant;
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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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