SADPMR Form PMS - Application for a special permit (s.4(1)(e) or 5(1)(e) Precious Metals Act)

1. For any enquiries, contact the office of the Regulator during office hours.

2. Complete the form in block letters and in black pen.

3. Where options are given mark the appropriate block.

4. Complete the form in English and do not use abbreviations.

5. Although the application forms are made available in electronic format, only a signed original hard copy shall be acceptable.

6. Ensure that all the required documentation accompanies the application.

7. The application must be submitted to the operational business premises of the Regulator. PART A : PARTICULARS OF APPLICANT

1. In the case of a natural person, please provide the following: (i) Surname: (ii) First name(s) (iii) Identity number: *(A certified copy of the applicant’s identity document must be attached.) (iv) Has the applicant ever been convicted of any criminal offence in terms of the Act or any other law? (Yes/No) If yes, furnish particulars on a separate sheet of paper. (b) In the case of a person other than a natural person, please indicate: CC Partnership/Joint venture Co. Other (specify) (i) Name of company, close corporation, partnership or joint venture: <!-- page break --> (i) Registration number of Co. or CC: _______________________________________________ (ii) Full names and identity number of managing director or member: (iii) Particulars of interest held (%) in the juristic person and name of the holder of the controlling interest: (iv) An indication of the precious metals to be acquired: (v) The purpose for which the precious metals will be used: (vi) Source from which precious metals will be obtained or how they will be disposed of (indicate place or person): (vii) Period for which a special permit is required: (viii) Description of the applicant’s technical ability: <!-- page break --> (ix) Details of applicant’s financial status: (x) Details of the target market and market requirements: *(In the case of a company or close corporation, a certified copy of a certificate of incorporation must be attached.) PART B: CORRESPONDENCE ADDRESS FOR THIS APPLICATION 2(a) Business address: (i) Building name: (ii) Building number: (iii) Street number: (iv) Street name: (v) Suburb: (vi) Town/City: (vii) Postal code: (viii) Province: (ix) Country: (x) Telephone number: (xi) Fax No: (xii) Cellphone No: (xiii) Email address: (b) Relevant postal address: (i) Postal address: (ii) Town/City: (iii) Postal code: <!-- page break --> PART C: THE APPLICATION MUST BE ACCOMPANIED BY THE FOLLOWING:

1. A certified copy of the applicant’s identity document, if applicable.

2. A certified copy of the certificate of incorporation and articles of association or founding statement, if applicable.

3. A copy of the relevant resolution, if acting in a representative capacity.

4. Documentary proof of the applicant’s registered business premises.

5. Documentary proof of the applicant’s technical ability.

6. Documentary proof of the applicant’s financial status or access to appropriate financial assistance.

7. The applicant’s business plan, inclusive of measures to comply with the broad-based socio- economic empowerment charter developed in terms of section 100 of the Mineral and Petroleum Resources Development Act, 2002 (Act No. 28 of 2002).

8. A tax clearance certificate.

9. A police clearance certificate.

10. A non-refundable prescribed application fee. PART D: DECLARATION I, the applicant, , hereby declare that the contents of this application are true and correct. Capacity: Signed at on the day of SIGNATURE OF APPLICANT/REPRESENTATIVE (IF APPLICABLE) <!-- page break -->