I,                                                                                  [fill in name of applicant], the undersigned, acting in my capacity as                                                   [fill in designation of applicant], hereby apply for a certificate referred to in section 1(2)(a) of the Extension of Security of Tenure Act, 1997 (Act No. 62 of 1997) authorising me to act as owner/person in charge [delete whichever is not applicable] for all purposes contemplated in that Act of the land described as:

[Give the full Deeds Office description of the land, if any. In the case of a farm, this must include the portion, name and number of the farm, and the name of the district in which the farm is situated.]

The grounds on which this application is based are as follows:

[List the grounds on which the application is based, including, in the case of a tribal authority, the grounds on which it is alleged that the applicant represents the tribe concerned. Attach additional pages if necessary.]

In support of this application I attach the following documents:

[List and attach any relevant supporting documents.]

Signed at                                                     [name of town or city] on this                       day of                                            

[Fill in the name of the district or closest town or city and today's date.]

[Signature and full name of applicant]

[Designation]

Applicant's return address (including tel.no., fax no. and contact person)

Applicant's telephone no.                                                                                          

Applicant's facsimile no.                                                                                              

Contact person