Regulations > Regulations relating to Debt Collectors, 2003 > Annexures > Annexure A : Forms

Form 1A

Application for registration as a debt collector by an officer in the employ of a juristic person, a director of a company or a member of a close corporation

[Regulation 2(1)]

Please note:

In the case of a person who has in the preceding 10 years been convicted of an offence of which violence, dishonesty, extortion or intimidation is an element, this application will only b considered upon receipt of proof of exemption by the Minister of Justice and Constitutional Development in terms of section 10(2) of the Debt Collectors Act, 1998 (Act No. 114 of 1998).

2. This form must be completed in block letters.

Please indicate:

New Registration

Transfer from other juristic person/company/close corporation

I,..........................................................................................(full names), hereby apply for registration as a debt collector and furnish the following particulars:

A. PERSONAL PARTICULARS

1.	Date of birth: ..............................................................................................................

2.	Nationality: ................................................................................................................

3.	Identity number: ........................................................................................................

(Attach a copy of identity document)

4.	Residential address: ...................................................................................................

................................................................................... Postal code ............................

5.	Telephone number: ...................................................................................................

6.	Postal address: ........................................................... Postal code ............................

7.	Occupation: ................................................................................................................

8	Business address: .......................................................................................................

................................................................................... Postal code ............................

9.	Telephone number: ....................................................................................................

10.	E-mail address: ...........................................................................................................

11.	Cellular number: .........................................................................................................

12.	Fax number: ................................................................................................................

13.

Are you on trial for an offence of which violence, dishonesty, extortion or intimidation is an element or have you in the preceding 10 years been convicted of such offence? *Yes/No. If so, give details and, in the case of a conviction, indicate whether an application for exemption in terms of section 10(2) has been lodged with the Minister for Justice and Constitutional Development:

...................................................................................................................................

14.	Have you ever, in terms of section 15 of the Act, been found guilty of improper conduct? *Yes/No. If so, give details:

..................................................................................................................................

15.	Have you ever been declared or certified by a competent authority to be of unsound mind? *Yes/No. If so, give details:

..................................................................................................................................

16.	Are you an unrehabilitated insolvent? *Yes/No. If so, give details:

..................................................................................................................................

17.	Were you previously the holder of a debt collector's certificate which has been withdrawn? *Yes/No. If so, give details:

..................................................................................................................................

B. LANGUAGE PROFICIENCY

State language(s) in which you are proficient and indicate level of proficiency as "Good", "Fair" or "Poor" in the appropriate space.

Language
Speak
Read
Write

C. EDUCATIONAL QUALIFICATIONS

1. Highest standard passed at school ..............................................................................

2. Year in which passed ..................................................................................................

Certificates, diplomas or degrees obtained	Name of educational institution or centre	Year obtained

D. EXPERIENCE

State experience, if any, relating to the functions of a debt collector:

.................................................................................................................................

..................................................................................................................................

E. PARTICULARS OF *JURISTIC PERSON/COMPANY/CLOSE CORPORATION

1. Name of *juristic person/company/close corporation:

..................................................................................................................................

2.	Date of registration: ..................................................................................................

3.	Registration number: .................................................................................................

4.	Full names and identity numbers of *officers/directors/members:

..................................................................................................................................

5. Business address: .......................................................................................................

................................................................................... Postal code ............................

6.	Postal address: ...........................................................................................................

................................................................................... Postal code ............................

7.	Registered address: ....................................................................................................

................................................................................... Postal code ............................

8.	Telephone number: ....................................................................................................

9.	Nature of business: .....................................................................................................

10.	In what capacity are you applying (e.g. officer, director, member)?

.................................................................................................................................

..................................................................................................................................

F.	OTHER PARTICULARS

Financial year: .......................................... to ......................................................

I declare that the particulars furnished by me are in all respects complete and correct.

Signed at ...................................... this ................ day of .....................................20 .............

...................................................................

Signature of Applicant

Remarks:

1.	In terms of the Regulations relating to Debt Collectors, 2002, it is an offence to furnish false or misleading particulars or information or make a false or misleading statement.

2.	A curriculum vitae and a copy of identity document must accompany the application.

*Delete whichever is not applicable.

[Form 1A substituted by regulation 4(a) of Notice No. R. 741 dated 29 July 2005]

Debt Collectors Act, 1998 (Act No. 114 of 1998)

Regulations

Regulations relating to Debt Collectors, 2003

Annexures

Annexure A : Forms

Form 1A : Application for registration as a debt collector by an officer in the employ of a juristic person, a director of a company or a member of a close corporation [Regulation 2(1)]