Form 2
ANNEXURE A
REGULATIONS RELATING TO DEBT COLLECTORS, 2002
APPLICATION FOR EXEMPTION
[Regulation 3(1)]
I, ____________________________________________________________________________ (full names and surname), *a director / member of / sole proprietor trading as ____________________________________ (name of *company / close corporation / business) hereby apply to be exempted from the disqualification contemplated in section 10(1)(a)(i) of the Debt Collectors Act, 1998 (Act No. 114 of 1998), and in support of this application submit the following information:
1. Identity number or date of birth: ___________________________________________
2. Nationality: ____________________________________________________________
3. Residential address: _____________________________________________________
______________________________________________________________________
____________________________________________ Postal code: _______________
4. Telephone number: ______________________________________________________
5. Postal address: _________________________________________________________
____________________________________________ Postal code: _______________
6. Work address: __________________________________________________________
___________________________________________ Postal code: ________________
7. Telephone number: ______________________________________________________
8. E-mail address: _________________________________________________________
9. Cellular number: ________________________________________________________
10. Fax number: ____________________________________________________________
11. Full particulars of offence(s) of which violence, dishonesty, extortion, or intimidation is an element, convicted of in the preceding 10 years.
Particulars of charge(s) convicted of: _________________________________________
Date(s) of conviction(s): ___________________________________________________
Particulars of sentence(s):__________________________________________________
12. The above-mentioned conviction(s) should not be a disqualification for exercising the occupation of debt collector as the circumstances relating to the commission of the offence were as follows:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I declare that the particulars furnished by me are in all respects complete and correct.
Signed at ____________________ this _____ day of ____________________ 20 _____
____________________
Signature of Applicant
*Delete whichever is not applicable
Remarks:
In terms of the Regulations relating to Debt Collectors, 2003, it is an offence to furnish false or misleading particulars or information or make a false or misleading statement.
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