ANNEXURE A
FORM 1B
REGULATIONS RELATING TO DEBT COLLECTORS, 2003
APPLICATION FOR REGISTRATION AS DEBT COLLECTOR BY A JURISTIC PERSON, A COMPANY OR A CLOSE CORPORATION
[Regulation 2(1)]
Please note:
1. In the case of an officer/director/member of a juristic person/company/close corporation who has in the preceding 10 years been convicted of an offence of which violence, dishonesty, extortion or intimidation is an element, this application will only be considered upon receipt of proof of exemption by the Minister for Justice and Constitutional Development in terms of section 10(2) of the Debt Collectors Act, 1998 (Act No. 114 of 1998).
2. This form must be completed in block letters in black ink.
I, ____________________________________________________________________________ (full names and surname), representative of __________________________________________ (name of *juristic person / company / close corporation), hereby apply on behalf of the aforementioned *juristic person / company / close corporation for registration as a debt collector and furnish the following particulars.
A. PARTICULARS OF *JURISTIC PERSON / COMPANY / CLOSE CORPORATION
1. Date of registration: ______________________________________________________
2. Registration number: _____________________________________________________
(Attach a copy of the registration document)
3. Full names, surname and identity numbers of *directors / members:
_____________________________________________________________________
4. Business address: _______________________________________________________
____________________________________________ Postal code: ________________
5. Postal address: _________________________________________________________
____________________________________________ Postal code: ________________
6. Registered address: ______________________________________________________
____________________________________________ Postal code: ________________
7. Business telephone number: ______________________________________________
8. E-mail address: _________________________________________________________
9. Fax number: ____________________________________________________________
10. Nature of business: ______________________________________________________
11. Period in business: _______________________________________________________
*Delete whichever is not applicable (Do not cross, tick or circle – answer “Yes” or “No”)
12. Are any of the *officers / directors / members on trial for an offence of which violence, dishonesty, extortion or intimidation is an element, or has any of the *officers / directors / members in the preceding 10 years been convicted of such offence? *Yes / No. If so give details and, in the case of a conviction, indicate whether an application for exemption in terms of section 10(2) has been lodged with the Minister for Justice and Constitutional Development:
_________________________________________________________________________________
13. Has any of the *officers / directors / members ever in terms of section 15 of the Act been found guilty of improper conduct? *Yes / No. If so, give details:
_________________________________________________________________________________
14. Has any of the *officers / directors / members ever been declared or certified by a competent authority to be of unsound mind? *Yes / No. If so, give details:
_________________________________________________________________________________
15. Is any of the *officers / directors / members an unrehabilitated insolvent? *Yes / No. If so, give details:
_________________________________________________________________________________
16. Was the *juristic person / company / close corporation or any of its *officers / directors / members, the holder of a debt collector’s certificate which has been withdrawn by the Council? *Yes / No. If so, give details:
_________________________________________________________________________________
B. OTHER PARTICULARS
1. Particulars of trust account (Attach confirmation letter from bank):
Bank: ________________________________________ Branch code: _____________
Account number: ________________________________________________________
2. Particulars of public accountant / auditor (Attach confirmation letter from accountant / auditor):
Full names: ____________________________________________________________
Address: _______________________________________________________________
_____________________________________________ Postal code: ______________
3. Telephone number: ______________________________________________________
4. Financial year: ____________________________ to ____________________________
5. State Bank particulars of account to be used in the case of a refund of an application fee (registration fee) and/or annual subscription fee in respect of an incorrect or incomplete application for registration:
Name of account: _________________________________________________
Bank: ___________________________________________________________
Account number: __________________________________________________
Branch code: _____________________________________________________
Type of account: __________________________________________________
(The particulars supplied must correspond with the banking particulars of the account out of which the payment in respect of this application was made.)
6. VAT registration number (if applicable): ________________________________
I declare that the particulars furnished by me are in all respects complete and correct.
Signed at ____________________ this _____ day of ____________________ 20 _____
________________________
Signature of representative
Remarks:
1. In terms of the Regulations promulgated in terms of the Debt Collectors Act 114 of 1998 it is an offence to furnish false or misleading particulars or information or make a false or misleading statement.
2. The trust account may not be used for the payment of application fees or annual subscription fees.
