QUESTIONNAIRE TO BE COMPLETED IN RESPECT OF AN APPLICANT

1.        Details of the Entity

1.1        Entity Name:

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1.2        Registration Number:

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1.3        Any other name under which the business is conducted and where is it used:

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1.4        Registered address, website address and email address:

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1.5        Postal address:

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1.6        Telephone and facsimile numbers of the applicant:

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1.7        Name, physical and, postal addresses and telephone numbers of the applicant's bank

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1.8        Name, Physical and, postal addresses and telephone numbers of the applicant's auditor

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2.        Specific test to determine the financial soundness of the applicant:

If the answer to a question is 'yes' please provide details. A separate schedule may be completed and attached to this questionnaire with proper referencing.

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(b)        Provide confirmation that the applicant maintains current assets which are at least sufficient to meet current liabilities.

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(d)        Has the applicant made arrangements or composition with creditors, filed for business rescue, filed for bankruptcy or winding-up?

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(e)        Has the applicant—

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DECLARATION

(to be completed by the chief executive officer/managing director on behalf of an applicant.)

I, the undersigned, (insert full first name(s) and surname) hereby certify that, to the best of my knowledge, the information given in the answers to the above questions are true, complete and accurate and not misleading in any respect.

I undertake that, as long as I continue to be a director of the registered credit rating agency, I will notify the registrar of any material changes to, or changes affecting the completeness or accuracy of the answers to the questions above as soon as possible, but in no event later than 21 days from the day that the change comes to my attention.

I hereby authorise the Financial Services Board, and its duly authorised verification agent, to request or confirm any information as well as any other information provided in support of this application (including but not limited to the South African  Police Service, the Government of the  Republic of

South Africa, industry bodies and associations, employers and any educational, training, credit bureau and fraud prevention organisations) for the purpose of verifying the information provided.

I authorise the data holders (including but not limited to the aforesaid institutions) to furnish information to the Financial Services Board and its duly appointed verification agent. I unconditionally indemnify the Financial Services Board, its verification agent and the data holders against any liability that may result from furnishing information in this regard.

Full name(s) and surname: ...........................................................................................................

Position held: ..............................................................................................................................

SIGNATURE: Chief Executive Officer / Managing Director ..............................................................

DATE .......................................................

Documents to be submitted

•        signed declaration; and