Form E
Application to Renew an Individual Licence
(Regulation 10)
Independent Communications Authority of South Africa
Note:
| (a) | Applicants must refer to the Electronic Communications Act, 2005 (Act No. 36 of 2005) ("the Act") and any regulations published under the Act with regard to the requirements to be fulfilled by applicants. |
| (b) | Information required in terms of this Form which does not fit into the space provided may be included in an appendix allocated to the Form. Each appendix must be numbered with reference to the relevant part of the Form. |
| (c) | Where any information in this Form does not apply to the applicant, the applicant must indicate that the relevant information is not applicable. |
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| 1.2 | Nature of services authorised to be provided in terms of the Licence: |
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| 1.3 | Expiry date of Licence: |
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| 1.3 | Attach a copy of the Licence that is the subject of this application. The copy of the Licence must be marked clearly as Appendix 1.4 of FORM E. |
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| 2. | PARTICULARS OF APPLICANT (LICENSEE) |
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| 2.1 | Full name of applicant: |
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| 2.2 | Designated contact person: |
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| 2.3 | Applicant's street address: |
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| 2.4 | Applicant's principal place of business (if different from street address): |
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| 2.5 | Applicant's postal address: |
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| 2.6 | Applicant's telephone number/s: |
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| 2.7 | Applicant's telefax number/s: |
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| 2.8 | E-mail address of designated contact person: |
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| 3. | OWNERSHIP AND MANAGEMENT |
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| 3.1 | Provide details of all ownership interests in the applicant and the identity and address of each holder of an ownership interest in the applicant. Where an applicant is a juristic person only shareholdings (or equivalent) of 5% or more of the total issued shares (or equivalent) in the applicant are relevant. |
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| 3.2 | Indicate whether the applicant is listed on any stock exchanger, and provide details of any such listing: |
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| 3.3 | In respect of each holder of any ownership interest in any person holding an ownership interest in the applicant, provide the details required in 3.1 in respect of each such holder: |
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| 3.4 | Indicate the extent to which any ownership interest referred to above is held by an historically disadvantaged person or group (including black people, women and disabled persons) or youth organisation. |
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| 3.5 | Indicate whether the holder of any ownership interest in the applicant is a foreign citizen or an entity registered or incorporated in any country other than South Africa: |
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| 3.6 | Indicate whether any person holding an ownership interest in the applicant holds a Licence issued in terms of the Act or holds an ownership interest in any other licensee licensed to provide a service similar to that to which this application relates: |
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| 3.7 | Provide particulars of any interest held by the applicant in another licensee licensed in terms of the Act: |
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| 3.8 | Provide details (including name, nationality, identification or passport number, position and address) of each member of the applicant's: |
| (i) | board of directors or similar body; and |
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| 4. | RADIO FREQUENCY SPECTRUM |
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| 4.1 | Indicate whether the applicant holds a radio frequency spectrum Licence. If so, provide details thereof and attach a copy of the radio frequency spectrum Licence marked clearly as Appendix 4.1 of FORM E: |
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| 4.2 | Indicate the date on which the applicant's radio frequency spectrum Licence expires. A separate application to renew the applicant's radio frequency spectrum Licence must be submitted to the Authority prior to the expiry of that Licence in terms of the applicable regulations. |
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| 5. | AMENDMENT TO THE LICENCE |
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| 5.1 | Indicate whether the applicant seeks any amendment to the Licence in terms of section 10(1)(c) of the Act, if this application to renew the Licence is granted. If so, a separate application for the amendment of the Licence in terms of the ICASA Licensing Processes and Procedures Amendment Regulations, 2010 must be submitted in this regard. |
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| 6. | FAILURE TO COMPLY WITH REQUIREMENTS |
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| 6.1 | Provide details of any action taken in relation to the applicant by the authority or any other person due to a breach or alleged breach by the licensee of the Act and related legislation. |
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| 6.2 | Provide details of any finding by the Complaints and Compliance Committee against the applicant, as well as details of the sanction imposed by the Authority, if any. |
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| 6.3 | Where the applicant is a broadcaster, provide details of any finding by a body recognised in terms of section 54 and 55 of the Act. |
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| 7.1 | Specify any undertakings which the applicant is prepared to make in order to promote the objects of the Act, if its Licence is renewed. |
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| 8. | LATE FILING OF APPLICATION |
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| 8.1 | Indicate if this application is filed with the Authority within the time period specified in the ICASA Licensing Processes and Procedures Amendment Regulations, 2010: |
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| 8.2 | Where this application is filed outside of this time period, set out the reasons for the late filing: |
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| 9.1 | Provide details of any matter which, in the applicant's view, the Authority should consider: |
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| 9.2 | Attach a resolution authorising the person signing this application to sign this application, marked clearly as Appendix 9.2 of FORM E. |
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The person signing the registration on behalf of the applicant must acknowledge as follows:
I acknowledge that the Authority reserves the right to have any Licence amended pursuant to this application set aside, should any material statement made herein, at any time, be found to be false.
Signed: ............................................................
(APPLICANT)
I certify that this declaration was signed and sworn to before me at .............................. on the .......... day of ............................... 20......, by the deponent who acknowledged that he/she:
| 1. | knows and understands the contents hereof; |
| 2. | has no objection to taking the prescribed oath or affirmation; and |
| 3. | considers this oath or affirmation to be truthful and binding on his/her conscience. |
COMMISSIONER OF OATHS
Name:
Address:
Capacity:
