Government Gazzette No. 27608, 20 May 2005, Notice R490

ANNEXURE

APPLICATION FOR A LICENCE TO PROVIDE
VALUE-ADDED NETWORK SERVICE (VANS)

1. PARTICULARS OF APPLICANT

1.1 Natural Persons

1.1.1 Name of Applicant:...............................................
1.1.2 Nature of business:..............................................
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1.1.3 Identification number of the applicant

1.1.4 Permanent residential address:...................................
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1.1.5 Principle place of business:.....................................
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1.1.6 Telephone number: (.....).......................
1.1.7 Fax number:       (.....).......................
1.1.8 Cellular number:  (.....).......................
1.1.9 Email address:...................................................

1.2 Juristic Persons

1.2.1 Address
1.2.1.1 Business name:.................................................
1.2.1.2 Nature of business.............................................
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1.2.1.3 Registration Number:

1.2.1.4 Principle place of business:...................................
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1.2.1.5 Postal address:................................................
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1.2.1.6 Telephone number: (.....).......................
1.2.1.7 Fax number:       (.....).......................
1.2.1.8 Email address:.................................................
1.2.1.9 Please attach certified copies of all the founding documents of
        the applicant to this application.
          - Founding statement for CC
          - Shareholders agreement
          - Application for conversion from company to CC
          - Certificate of incorporation
          - Memorandum of association
          - Certificate of Incorporation for Section 21 Company
          - Deed of Trust
          - Certificate of change of name of company
          etc.

2. Description of the Service (use additional page(s) if required)
Please tick the applicable blocks(s)

A description of the proposed service(s) to be provided:...............
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3. EMPOWERMENT

(a) The empowerment strategies related to Black Economic Empowerment,
    with intended time frames.
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(b) Empowerment achieved already in areas such as management and control
    structures skills development, enterprise development and
    procurement.
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4. Any other information the applicant deems relevant.
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