Lotteries Act, 1997 (Act No. 57 of 1997)

A1

Name of organization

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A2

Postal address:

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Postal Code:

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A3

Street address:

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Province:

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A4

Telephone number:

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Fax number:

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A5

E-mail address:

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A6

When was your organization formed: ................................................................................................

A7

What kind of registered organization are you?

(e.g. Non-Profit Organization, Section 21 Company, Public Benefit Trust):

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

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A8

When was your organization registered?

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A9

Registration number: (Please attach a copy of your registration certificate)

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A10

Details of the main contact person with executive powers (e.g. Manager/Programme Director)

Name:

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Position:

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South African I.D. Number: (Attach Certified Copy of ID)

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Address:

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Tel:

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A11

Details of a second contact person (e.g. Chairperson): (e.g. Chairperson):

Name:

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Position:

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South African I.D. Number: (Attach Certified Copy of ID)

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Address:

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

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

Tel:

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A12

Names and positions of the Members of the Management Committee: (Members are required to attach certified copy of ID):

1

Name:

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Position:

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I.D. Name:

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

Tel:  ...............................................

2

Name:

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

Position:

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

I.D. Name:

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

Tel: .................................................

3

Name:

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

Position:

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

I.D. Name:

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

Tel: ................................................

4

Name:

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

Position:

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

I.D. Name:

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

Tel: ...............................................

5

Name:

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

Position:

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

I.D. Name:

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

Tel: ..............................................

A13

Are you affiliated to any organizations? ....................................................................

If Yes, name them: .....................................................................................................

A14

Are you an umbrella body? ..........................................................................................

If Yes, what organization are you affiliated to:

........................................................................................... (Attach a list if necessary)

A15

Describe the main purpose of your organization:

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

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

A16

Describe the nature of services and/or products that your organization provides AND the people who will benefit from the services and/or products:

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

A17

In which province/s do you operate? (Tick next to the province/s that apply to  you)

Eastern Cape .........................Free State ............................Gauteng .............................

Kwa Zulu Natal ......................Limpopo...............................Mpumalanga ......................

Northern Cape ......................North West ..........................Western Cape.....................

A18

Please fill in the information below on your staff composition

A19

Please provide current employment equity status/equity plan for your organization