I, .............................................................................................................................................................................................(name and surname) ......................... (identity number) employed as a ............................................................................................................................................................................................................................................................................................................................................................designation) at ........................................................................................................................................................ (employer) situated at the following address:

......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................., hereby declares as follows:

(a) I have sent the following document ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... (description of the document) with the following reference number ...................................................... and which is dated .................................................................................,to the following facsimile number ..........................................................................................................................................................................

(b) Subsequent to the sending of the above facsimile I -

(i) obtained the attached transmission verification report as to whether the document was successfully transmitted to the facsimile number of the person/organisation; and

(ii) telephonically confirmed with a person who identified himself/herself as....................................................... (name and surname) who is employed at.....................................................................................................................................................as a ......................................................................(designation) with the following identity number ..................................................................................................................................................., that the facsimile was received by him or her.

Date: ..........................................................................................................

Signature of person: ...................................................................................