Form 1C
ANNEXURE A
FORM 1C
REGULATIONS RELATING TO DEBT COLLECTORS, 2003
APPLICATION FOR REGISTRATION AS DEBT COLLECTOR BY A PERSON OTHER THAN AN OFFICER IN THE EMPLOY OF A JURISTIC PERSON, A DIRECTOR OF A COMPANY OR A MEMBER OF A CLOSE CORPORATION
[Regulation 2(1)]
Please note:
1. In the case of a person 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 and black ink.
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Please indicate:
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New Registration
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Transfer from other juristic person / company / close corporation
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In the case of a transfer:
· State name of previous juristic person, company or close corporation
__________________________________________________________________________
· Council registration number: __________________________________________________
Please attach original registration certificate.
I, ____________________________________________________________________________ (full names and surname), hereby apply for registration as a debt collector and furnish the following particulars:
A. PERSONAL PARTICULARS
1. Date of birth: ___________________________________________________________
2. Nationality: _____________________________________________________________
3. Identity number: _________________________________________________________
(Attach a copy of identity document)
4. Residential address: _____________________________________________________
____________________________________________ Postal code: ________________
5. Telephone number: ______________________________________________________
6. Postal address: _________________________________________________________
____________________________________________ Postal code: ________________
7. Occupation: ____________________________________________________________
8. Business address: _______________________________________________________
____________________________________________ Postal code: ________________
9. Telephone number: ______________________________________________________
10. E-mail address: _________________________________________________________
11. Cellular number: _________________________________________________________
12. Fax number: ____________________________________________________________
* Delete whichever is not applicable (Do not cross, tick or circle – answer “Yes” or “No”)
13. Are you on trial for an offence of which violence, dishonesty, extortion or intimidation is an element or have you in the preceding 10 years been convicted of such an 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 of Justice and Constitutional Development:
_______________________________________________________________________
14. Have you ever, in terms of section 15 of the Act, been found guilty of improper conduct? *Yes / No. If so, give details:
_______________________________________________________________________
15. Have you ever been declared or certified by a competent authority to be of unsound mind? *Yes / No. If so, give details:
_______________________________________________________________________
16. Are you an unrehabilitated insolvent? *Yes / No. If so, give details:
_______________________________________________________________________
17. Were you previously the holder of debt collector’s certificate which has been withdrawn? *Yes / No. If so, give details:
_______________________________________________________________________
18. Have you already attained the age of 18? *Yes / No.
_______________________________________________________________________
B. LANGUAGE PROFICIENCY
State language(s) in which you are proficient and indicate level of proficiency as “Good”, “Fair” or “Poor” in the appropriate space.
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Language
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Speak
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Read
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Write
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C. EDUCATIONAL QUALIFICATIONS
1. Highest standard passed at school: __________________________________________
2. Year in which passed: _____________________________________________________
3. Certificates, diplomas, or degrees obtained:
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Certificates, diplomas or degrees obtained
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Name of educational institution or centre
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Year obtained
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D. EXPERIENCE
State experience, if any, relating to the functions of a debt collector:
_______________________________________________________________________
E. PARTICULARS OF BUSINESS
1. Name under which business will be conducted:
_______________________________________________________________________
2. Business address: _______________________________________________________
______________________________________________ Postal code: _____________
3. Business telephone number: _______________________________________________
4. Postal address: _________________________________________________________
______________________________________________ Postal code: _____________
5. Particulars of trust account (Attach confirmation letter from bank):
Bank: ________________________________________ Branch code: _____________
Account number: ________________________________________________________
6. Particulars of public accountant / auditor (Attach confirmation letter from accountant / auditor):
Full names: ____________________________________________________________
Business address: _______________________________________________________
_____________________________________________ Postal code: ______________
7. Telephone number: ______________________________________________________
8. Fax number: ____________________________________________________________
9. Capacity of applicant (e.g. owner, partner, employee):
_______________________________________________________________________
F. OTHER PARTICULARS
1. Financial year: ____________________________ to ____________________________
2. 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.)
3. 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 Applicant
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. A curriculum vitae and a copy of your identity document must accompany the application.
3. The trust account may not be used for the payment of application fees or annual subscription fees.
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