Form 2

Application for exemption

[Regulation 3(1)]

I, ........................................................................... (full names), *a director/member of ....................................................................................(name of *company/close corporation) hereby apply to be exempted from the disqualification contemplated in section 10(1)(a)(i) of the Debt Collectors Act, 1998 (Act No. 114 of 1998), and in support of this application submit the following information:

1.        Identity number or date of birth: ....................................................................................

2.        Nationality: ....................................................................................................................

3.        Residential address: .......................................................................................................

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

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

............................................................................  Postal code: ......................................

4.        Telephone number: .......................................................................................................

5.        Postal address: ..............................................................................................................

............................................................................  Postal code: ......................................

6.        Work address: ................................................................................................................

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

............................................................................  Postal code: ......................................

Particulars of charge(s) convicted of: ..............................................................................

Date(s) of conviction(s): .................................................................................................

Particulars of sentence(s): ..............................................................................................

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

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

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

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

I declare that the particulars furnished by me are in all respects complete and correct.

Signed at ...................................... this ................ day of  .....................................20 .............

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

Signature of Applicant

*Delete if not applicable

Remarks:

In terms of the Regulations relating to Debt Collectors, 2003, it is an offence to furnish false or misleading particulars or information or make a false or misleading statement.