Form G
Application to Transfer Ownership and/or Control of an Individual Licence
(Regulation 11)
Independent Communications Authority of South Africa
Note:
| (a) |
Applicants must refer to the Electronic Communications Act, 2005 (Act No. 36 of 2005) ("the Act") and any regulations published under that Act with regard to the requirements to be fulfilled by applicants. |
| (b) |
Information required in terms of this Form which does not fit into the space provided may be included in an appendix attached to the Form. Each appendix must be numbered with reference to the relevant part of the Form. |
| (c) |
Where any information in this Form does not apply to the applicant, the applicant must indicate that the relevant information is not applicable. |
| 1. |
PARTICULARS OF LICENCE |
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| 1.2 |
Nature of services authorised to be provided in terms of the Licence: |
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| 1.3 |
Attach a copy or copies of the Licence/s that is the subject of this application. The copy of the Licence must be marked clearly as Appendix 1.3 of FORM G.
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| 2. |
PARTICULARS OF THE APPLICANT (LICENSEE) |
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| 2.1 |
Full name of the applicant: |
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| 2.2 |
Designated contact person: |
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| 2.3 |
Applicant's street address: |
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| 2.4 |
Applicant’s principal place of business (if different from street address): |
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| 2.5 |
Applicant’s postal address: |
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| 2.6 |
Designated contact person’s telephone number/s (including mobile): |
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| 2.7 |
Designated contact person's telefax number/s: |
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| 2.8. |
E-mail address of designated contact person: |
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3. |
PARTICULARS OF TRANSFEREE |
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| 3.1 |
Full name of transferee: |
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| 3.2 |
Designated contact person: |
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| 3.3 |
Transferee's street address: |
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| 3.4 |
Transferee’s principal place of business (if different from street address): |
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| 3.5 |
Transferee's postal address: |
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| 3.8 |
E-mail address of the designated contact person: |
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| 4. |
LEGAL FORM OF THE APPLICANT (LICENSEE) |
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| 4.1 |
Indicate if the applicant is: |
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| 4.2 |
If the applicant is a natural person or a partnership: |
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| 4.2.1 |
Provide the identity number of the applicants or each partner in the applicant: |
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| 4.2.2 |
Attach a certified copy of the identity document of the applicant or certified copies of the identity document of each partner in the applicant marked clearly as Appendix 4.2.2 of FORM G, indicating that he or she is a citizen of the Republic, as required by section 5(8)(a) of the Act. |
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| 4.3 |
If the applicant is a juristic person: |
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| 4.3.1 |
Indicate the legal form of the applicant (e.g. private company incorporated in terms of the Companies Act, 1973): |
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| 4.3.2 |
Registration number of applicant: |
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| 4.3.3 |
Attach certified copies of the applicant’s certificate of incorporation and memorandum and articles of association or other constitutive documents of the applicant (e.g. memorandum and articles of association, association agreement, constitution) marked clearly as Appendix 4.3.3 of FORM G, indicating the applicant’s compliance with the requirements of section 5(8)(b) of the Act. |
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| 4.4 |
Where the applicant has been liquidated or sequestrated, provide: |
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| 4.4.1 |
Liquidator / Executor’s postal address: |
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| 4.4.2 |
Liquidator / Executor’s telephone number/s: |
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| 4.4.3 |
Liquidator/Executor’s mobile number/s: |
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| 4.4.4 |
Liquidator / Executor’s telefax number/s: |
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| 4.4.5 |
Liquidator / Executor’s E-mail address: |
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| 4.4.6 |
Attach an affidavit deposed to by the liquidator or executor, indicating the consent to the transfer of the Licence, marked clearly as Appendix 4.4.5 of FORM G. |
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| 5. |
LEGAL FORM OF TRANSFEREE |
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| 5.1 |
Indicate if the transferee is: |
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| 5.2 |
If the transferee is a natural person or a partnership: |
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| 5.2.1 |
Provide the identity number of the transferee or each partner in the transferee: |
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| 5.2.2 |
Attach a certified copy of the identity document of the transferee or certified copies of the identity document of each partner in the transferee marked clearly as Appendix 5.2.2 of FORM G, indicating that he or she is a citizen of the Republic, as required by section 5(8)(a) of the Act. |
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| 5.3 |
If the transferee is a juristic person: |
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| 5.3.1 |
Indicate the legal form of the transferee (e.g. private company incorporated in terms of the Companies Act, 1973): |
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| 5.3.2 |
CIPC Registration number of transferee: |
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| 5.3.3 |
Attach certified copies of the transferee’s certificate of incorporation and memorandum and articles of association or other constitutive and/or other governing documents of the transferee (e.g. memorandum and articles of association, association agreement, constitution) marked clearly as Appendix 5.3.3 of FORM G, indicating the transferee’s compliance with the requirements of section 5(8)(b) of the Act. |
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| 5.4 |
If the transferee is not a juristic person but intends to operate as one if this application is granted: |
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| 5.4.1 |
Provide a written undertaking that the transferee will comply with section 5(8)(b) of the Act marked clearly as Appendix 5.4.1 of FORM G. |
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6. |
OWNERSHIP AND MANAGEMENT OF APPLICANT |
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| 6.1 |
Provide details of all ownership interests in the applicant and the identity and address of each holder of an ownership interest in the applicant. Where an applicant is a juristic person, only shareholdings (or equivalent) of 5% or more of the total issued shares (or equivalent) in the applicant are relevant. Attach as Appendix 6.1 of FORM G
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| 6.2 |
Indicate whether the applicant is listed on any stock exchange, and provide details of any such listing: Attach as Appendix 6.2 of FORM G
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| 6.3 |
In respect of each holder of any ownership interest in any person holding an ownership interest in the applicant, provide the details required in 6.1 in respect of each such holder: Attach as Appendix 6.3 of FORM G
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| 6.4 |
Indicate the extent to which any ownership interest referred to above is held by an historically disadvantaged person |
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| 6.5 |
Indicate whether the holder of any ownership interest in the applicant is a foreign citizen or an entity registered or incorporated in any country other than South Africa: |
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| 6.6 |
Indicate whether any person holding an ownership interest in the applicant holds a Licence issued in terms of the Act or holds an ownership interest in any other licensee licensed to provide a service similar to that to which this application relates: |
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| 6.7 |
Provide particulars of any interest held by the applicant in another licensee licensed in terms of the Act: |
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| 6.8 |
Provide details (including name, nationality, identification or passport number, position and address) of each member of the applicant’s: |
| (i) |
board of directors or similar body; and |
Attach as Appendix 6.8 of FORM G
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7. |
OWNERSHIP AND MANAGEMENT OF TRANSFEREE |
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| 7.1 |
Provide details of all ownership interests in the transferee and the identity and address of each holder of an ownership interest in the transferee if a natural person. Where a transferee is a juristic person, indicate all the shareholders and the percentage shares held by each shareholder. Attach as Appendix 7.1 of FORM G
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| 7.2 |
Provide a written undertaking indicating the correctness of the information stated in 7.1 signed off by Accounting Officer clearly marked Appendix 7.1 of FORM G.
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| 7.3 |
Indicate whether the transferee is listed on any stock exchange, and provide details of any such listing. |
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| 7.4 |
Provide a written undertaking indicating the stated in 7.3 signed off by Accounting Officer clearly marked Appendix 7.3 of FORM G. |
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| 7.5 |
In respect of each holder of any ownership interest in any person holding an ownership interest in the transferee, provide the details required in 7.1 in respect of each such holder. |
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| 7.6 |
Provide a written undertaking indicating the stated in 7.5 signed off by Accounting Officer clearly marked Appendix 7.5 of FORM G. |
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| 7.7 |
Indicate the extent to which any ownership interest referred to above is held by historically disadvantaged groups. |
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| 7.8 |
Provide a written undertaking indicating the stated in 7.7 signed off by Accounting Officer clearly marked Appendix 7.7 of FORM G. |
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| 7.9 |
Indicate whether the holder of any ownership interest in the transferee is a foreign citizen or an entity registered or incorporated in any country other than South Africa: |
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| 7.10 |
Provide a written undertaking indicating the stated in 7.9 signed off by Accounting Officer clearly marked Appendix 7.9 of FORM G. |
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| 7.11 |
Indicate whether any person holding an ownership interest in the transferee holds a Licence issued in terms of the Act or holds an ownership interest in any other licensee licensed to provide a service similar to that to which this application relates: |
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| 7.12 |
Provide a written undertaking indicating the stated in 7.11 signed off by Accounting Officer clearly marked Appendix 7.11 of FORM G.
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| 7.13 |
Provide particulars of any interest held by the transferee in another licensee licensed in terms of the Act: |
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| 7.14 |
Provide a written undertaking indicating the stated in 7.13 signed off by Accounting Officer clearly marked Appendix 7.13 of FORM G.
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| 7.15 |
Provide details (including name, nationality, identification or passport number, position and address) of each member of the transferee’s: |
| (i) |
board of directors or similar body; and |
Attach as Appendix 7.15 of FORM G
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| 8. |
SUITABILITY OF TRANSFEREE |
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| 8.1 |
Provide particulars of any Licence held by the transferee in terms of the Act, which has been revoked. Attach as Appendix 8.1 of FORM G
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| 8.2 |
Provide particulars of any application submitted by the transferee for a Licence in terms of the Act, which was rejected: Attach as Appendix 8.2 of FORM G
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| 8.3 |
Provide particulars of any application submitted by the transferee for a Licence in terms of the Act which is pending before the Authority: Attach as Appendix 8.3 of FORM G
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| 8.4 |
Provide details of any action taken in relation to the transferee by the Authority or any other person due to a breach of the Act and related legislation. |
Attach as Appendix 8.4 of FORM G
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| 8.5 |
Provide a written undertaking indicating the stated in 8.1, 8.2, 8.3 and 8.4 signed off by Accounting Officer clearly marked Appendix 8.5 of FORM G.
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| 8.6 |
Provide details of the transferee’s 5-year business plan in respect of the application: |
Attach as Appendix 8.6 of FORM G
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| 8.7 |
Attach a comprehensive business plan stated in 8.6 clearly marked Appendix 8.7 of FORM G.
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| 8.8 |
Provide separately and mark clearly as Appendix 8.8 of FORM G, copies of the transferee’s audited annual financial statements for the previous three years. |
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| 8.9 |
Provide detailed network architecture layout plan and roll-out plans should this application be granted indicating timeframes and roll-out targets clearly marked Appendix 8.9 of FORM G. |
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| 8.10 |
Applicable to Individual ECS/ECNS only: provide detailed proposed commercial agreements to be made available in terms of roaming, interconnection, facilities leasing clearly marked Appendix 8.10 of FORM G
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| 9. |
OWNERSHIP AND CONTROL BY HISTORICALLY DISADVANTAGED PERSONS, COMPETITION ANALYSIS AND CONSUMER INTEREST |
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| 9.1 |
Provide details of how the parties comply with the 30% ownership and control interest by historically disadvantaged groups clearly marked Appendix 9.1 of FORM G. |
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| 9.2 |
Provide an independent competition analysis report regarding the impact of this transaction on the relevant market clearly marked Appendix 9.2 of Form G.
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| 9.3 |
Provide a consumer interest analysis report post the transaction clearly market Appendix 9.3 Form G
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| 10. |
REASONS FOR PROPOSED TRANSFER |
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| 10.1 |
Provide the detailed reasons for the proposed transfer clearly marked Appendix 10.1 of FORM G.
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| 11. |
APPLICANT’S LICENCE OBLIGATIONS |
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| 11.1 |
Indicate those obligations of the applicant in terms of the Licence which have been discharged and those which will assumed by the transferee, should this application be granted:
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| 11.2 |
Provide separately and mark clearly as Appendix 11.2 of FORM G, a written undertaking given by the transferee, through its duly authorised representative, that it will comply with the applicant’s Licence obligations in the event of the transfer application being approved by the Authority. |
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| 12.1 |
Specify any undertakings which the transferee is prepared to make in order to promote the objects of the Act, should this application be approved by the Authority. Clearly marked as Appendix 12 of FORM G
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| 13. |
COMPLIANCE WITH CHAPTER 9 OF THE ACT |
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This section is only applicable where the Licence to be transferred is in respect a broadcasting service.
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| 13.1 |
Indicate whether the transferee is a member of the Advertising Standards Authority or intends to become a member: |
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| 13.2 |
Indicate whether the transferee is a member of a body contemplated in section 54(3) of the Act or intends to become a member: |
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| 13.3 |
Indicate whether the transferee is a party, movement, organisation, body or alliance which is of a party-political nature. |
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| 13.4 |
Indicate whether the transferee controls a newspaper, and, if so, provide details of: |
| 13.4.1 |
newspaper’s circulation figures |
| 13.4.2 |
area in which the newspaper is distributed |
| 13.4.3 |
newspaper’s market share. |
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| 14.1 |
Provide details of any other matter of which, in the applicants’ view, the Authority should be aware: |
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| 14.2 |
Attach a resolution authorising the persons signing this application to sign this application marked clearly as Appendix 14.2 of FORM G. |
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The persons signing the application on behalf of the applicant and the transferee must acknowledge as follows:
I, the applicant, acknowledge that the Authority reserves the right to have any Licence amended pursuant to this application set aside, should any material statement made herein, at any time, be found to be false.
Signed: ............................................................
(APPLICANT)
I certify that this declaration was signed and sworn to before me at .............................. on the .......... day of ............................... 20......, by the deponent who acknowledged that he/she:
| 1. |
knows and understands the contents hereof; |
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has no objection to taking the prescribed oath or affirmation; and |
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considers this oath or affirmation to be truthful and binding on his/her conscience. |
COMMISSIONER OF OATHS
Name:
Address:
Capacity:
[Form G substituted by regulation 9 of Notice 154 of 2016, GG 39871, dated 30 March 2016]
Gas Regulator Levies Act, 2002
