Broad-Based Black Economic Empowerment Act, 2003 (Act No. 53 of 2003)

Regulations

Purchase

BROAD-BASED BLACK ECONOMIC EMPOWERMENT COMMISSION

FORM: B-BBEE 17

APPLICATION FOR DEVIATION/EXEMPTION

(in terms of Section 10(2) of the Act)

(Please complete the application in full. Use additional paper if necessary)

SECTION A: APPLICANT INFORMATION

Name:

Identity/Registration Number:

Address:

Telephone Number:

Email Address:

Indicate if Public entity/Private/Organ of state:

SECTION B: DETAILS FOR DEVIATION

INDICATE:

➢	the elements that an organ of state or public entity requires to deviate from:

➢	the extent of deviation:

➢	proposed scorecard:

B-BBEE Element	Required scorecard	Scorecard below target	Proposed scorecard

SECTION C: DETAILS FOR EXEMPTION

INDICATE:

➢	what an organ of state or public entity requires to be exempted from:

➢	Give verifiable facts for exemption:

SECTION D: STATEMENT OF INTENT

(Briefly describe why deviation/exemption is needed)

SECTION E: ADDITIONAL REQUIRED INFORMATION

(Attach Business Plan or Motivation for exemption or deviation)

SECTION E: SIGNATURE(S)

(By signing below, you attest that the information is true and correct:

(1) Full Names: Signature Designation