1.

Name of licensee ......................................................................................................

2.

License number ........................................................................................................

3.

Type of licence .........................................................................................................

4.

Date on which the Energy Regulator issued the licence .............................................

5.

Details of the licensed facility/area ..........................................................................

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

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

6.

Details of mandated representative, including:

(a)

designation ............................................................................................

(b)

family name ...........................................................................................

(c)

first name ..............................................................................................

(d)

telephone number .................................................................................

(e)

fax number ............................................................................................

(f)

email address .........................................................................................