Regulations > Precious Metals Regulations > Annexures > Annexure C : Forms > Form PMS : Application for Special Permit

FORM PMS

Application No: _

South African Diamonds and Precious Metals Regulator

South African Diamond Centre, Cnr Main and Phillip Streets,

Johannesburg. PO Box 16001, Doornfontein, 2028’

APPLICATION FOR A SPECIAL PERMIT AS CONTEMPLATED IN SECTION 4(1)(e) OR SECTION 5(1)(e)

[In terms of section 4(1)(e) or 5(1)(d) of the Precious Metals Act, 2005 (Act 37 of 2005)]

Instructions:

1.	For any enquiries, contact the office of the Regulator during office hours.

2.	Complete the form in block letters and in black pen.

3.	Where options are given mark the appropriate block.

4.	Complete the form in English and do not use abbreviations.

5.	Although the application forms are made available in electronic format, only a signed original hard copy shall be acceptable.

6.	Ensure that all the required documentation accompanies the application.

7.	The application must be submitted to the operational business premises of the Regulator.

Part A : Particulars of applicant

1a)	In the case of a natural person, please provide the following: .

Surname:

_________________________________________________

ii)	First name(s):

_________________________________________________

iii)	Identity number:

_________________________________________________

*(A certified copy of the identity document must be attached.)

iv)	Has the applicant ever been convicted of any criminal offence in terms of the Act or any other law? (Yes/No) If yes, furnish particulars on a separate sheet of paper.

b)	In the case of a person other than a natural person, please indicate:

CC.____________Partnership/Joint venture _____________

Co. ____________Other (specify) _____________________

i)	Name of company, close corporation, partnership or joint venture:

_________________________________________________________

ii)	Registration number of Co. or CC:

_________________________________________________________

iii)	Full names and identity number of managing director or member:

_________________________________________________________

iv)	Particulars of interest held (%) in the juristic person and name of the holder of the controlling interest:

_________________________________________________________

v)	An indication of the precious metals to be acquired:

_________________________________________________________

vi)	The purpose for which the precious metals will be used:

_________________________________________________________

vii)	Source from which precious metals will be obtained or how they will be disposed of (indicate place or person):

_________________________________________________________

viii)

Period for which a special permit is required

_________________________________________________________

ix)	Description of applicant's manufacturing ability:

_________________________________________________________

x)	Details of applicant's financial status:

_________________________________________________________

xi)	Details of the target market and market requirements:

_________________________________________________________

*(In the case of a company or close corporation, a certified copy of a certificate of incorporation must be attached.)

PART B: CORRESPONDENCE ADDRESS FOR THIS APPLICATION

2a)	Business address:

i)	Building name:

ii)	Building number:

iii)	Street number:

iv)	Street name:

Suburb:

vi)	Town/City:

vii)	Postal code:

viii)

Province:

ix)

Country:

x)	Telephone number:

xi)

Fax No:

xii)	Cellphone No:

xiii)

Email address:

b)	Relevant postal address:

i)	Postal address:_________________________________

______________________________

ii)	Town/City:_____________________________________

iii)	Postal code:____________________________________

(Attach documentary proof of the registered business premises.)

THE APPLICATION MUST BE ACCOMPANIED BY THE FOLLOWING:

1.	A certified copy of the applicant's identity document, if applicable.

2.	A certified copy of the certificate of incorporation and the articles of association or founding statement, if applicable.

3.	A copy of the relevant resolution, if acting in a representative capacity.

4.	Documentary proof of the applicant's registered business premises.

5.	Documentary proof of the applicant's technical ability.

6.	Documentary proof of the applicant's financial status or access to appropriate financial assistance.

7.	The applicant's business plan, inclusive of measures to comply with the broad-based socio-economic empowerment charter developed in terms of section 100 of the Mineral and Petroleum Resources Development Act, 2002 (Act 28 of 2002).

8.	A tax clearance certificate.

9.	A police clearance certificate.

10.	A non-refundable prescribed application fee.

PART C: DECLARATION

I, the applicant,___________________________________________________, hereby declare that the contents of this application are true and correct.

Capacity: _

Signed at________________________________on the_________day of_________________

_______________________________________________________

SIGNATURE OF APPLICANT/REPRESENTATIVE (IF APPLICABLE)

Precious Metals Act, 2005 (Act No. 37 of 2005)

Regulations

Precious Metals Regulations

Annexures

Annexure C : Forms

Form PMS : Application for a Special Permit as Contemplated in Section 4(1)(e) or Section 5(1)(e)