FORM 5 Application for Transfer of Gambling Establishment Licence

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FORM 5 Application for Transfer of Gambling Establishment Licence
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 gambling establishment licence 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 gambling establishment:
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3. Postal address of the gambling establishment:
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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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