ICASA_Landmobile_App.. - Two Way Radios South Africa

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SECTION 3:CLIENT INFORMATIONCompanyTrading NameDepartmentRegistration No.Tax No.TitleInitialsSurnameID No.NationalityArea CodeTel (B)Area CodeTel (H)Area CodeFax NoCellE-MailBusiness or Residential AddressBuilding/Farm/PlotStreet No.StreetSuburbCity/TownPostal codePostal Address if different from the abovePostal codeAccount InformationSurname of person responsible for payment of the accountTitle Initials Job Title or PositionName of branch or division responsible for payment of the accountPostal addressPostal codeArea Code Tel (B) Area Code Tel (H)Area CodeFax NoCellIf you are already in possession of the radio equipment state date on which acquiredLicence number of previous ownerName and address of previousowner
SECTION 3: CLIENT INFORMATION (continued)Next of kin: (If applicant is a private person furnish name and address of next of kin not living with you)Title Initials SurnameID No.RelationshipArea Code Tel (B) Area Code Tel (H)Area Code Fax No. CellResidential AddressPostal CodePostal AddressPostal CodeNote that should the applicant be under the age of 18 the following should be completedDetails of GuardianTitle Initials SurnameID No.RelationshipArea CodeTel (B)Area CodeTel (H)Area CodeFax No.CellResidential AddressPostal CodePostal AddressPostal Code Postal CodeAgreement by applicant (must only be signed by applicant)I/We understand that if my/our application is approved the licence will be subjected to the provisions of the Electronic CommunicationsAct, 2005 (Act No. 36 of 2005) and the Regulations made thereunder, as amended from time to time.SURNAME IN CAPITAL LETTERSCapacityDateSignature
Page 1 and 2: Official use onlyIndependent Commun
Page 3 and 4: Official use onlyA P P E N D I X AN
Page 5: APPENDIX A: DETAILS OF FIXED & MOBI

ICASA_Landmobile_App.. - Two Way Radios South Africa

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