FPB 18/EC: Section 22 AND 23 of the Films and Publications Act, 1996

FILM AND PUBLICATION BOARD

13th Floor Pleinpark Building Private Bag X9069 Cape Town 8000

Tel (021) 465 6518  Fax (021) 465 6511

The Board may refuse to process your application if this form is not completed fully

(For Office Use) Ref. No.                                                              Date Received:

APPLICATION FOR EXEMPTION, dated .......................................................................................

Applicant ..................................................................................................................................

Address .....................................................................................................................................

Tel.......................................Fax.................................E-mail......................................................

Contact Person..........................................................................................................................

Title and Version of Game .........................................................................................................

Year of Production .................................Country of Origin ........................................................

Name of Publisher ....................................................................................................................

Proof of right to distribute the game in the Republic .................................................................

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Description of Game Play .........................................................................................................

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Reasons or Grounds for Exemption............................................................................................

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If the game does not contain contentious material, please complete the following statement:

I, ........................................................................................................................the undersigned, hereby state that the game forming the subject of this application does not contain any contentious material and is suitable for play by a child without parental guidance or supervision.  A copy of the advertisement intended to be used to advertise and promote this game is attached hereto.

Signed: ......................................................................................................................................

Capacity if on behalf of a firm ....................................................................................................