FORM C

NOTICE OF SURRENDER OF RADIO FREQUENCY SPECTRUM LICENCE

2. PARTICULARS OF LICENCE

1.1 Licence number

1.2 Nature of services authorised to be provided in terms of the Licence:

1.3 Expiry date of Licence:

1.4 Date on which surrender of Licence is to take effect:

1.5 Attach a copy of the Licence that is the subject of this notice marked clearly as Annexure A of FORM C 1.

3. PARTICULARS OF LICENSEE

2.1 Full name of licensee:

2.2 Designated contact person:

2.3 Licensee's street address:

2.4 Licensee's principal place of business (if different from street address):

2.5 Licensee's postal address:

2.6 Licensee's telephone number/s:

2.7 Licensee's telefax number/s:

2.8 E-mail address of designated contact person:

4. PARTICULARS OF OTHER LICENCES

Indicate if the licensee holds any other Licences issued in terms of the Act and whether the licensee intends also to surrender any other such Licences. If so, separate notices of surrender in respect of such Licences must be submitted in this regard:

5. STEPS TO INFORM SUBSCRIBERS AND END-USERS

Provide details of the steps the licensee proposes to take to inform end-users of the proposed cessation of the services in respect of which the Licence was granted, any migration plans and the expected impact on consumers:

6. EQUIPMENT

6.1 Please provide an inventory of all radio apparatus and an e-waste management plan attached hereto.

7. FEES PAYABLE

7.1 Indicate those fees and contributions which will be due and payable by the date on which the surrender of the Licence is to take effect and, the amount of such fees and contributions:

7.2 Specify the number of months which will have elapsed from the date on which the Licence was issued or from the last anniversary of the date on which the Licence was issued, as the case may be:

7.3 Indicate those annual fees and contributions payable at a date subsequent to the date on which the surrender of the Licence will take effect, and the proportionate amount which must be paid to the Authority, where this can be calculated as at the date of this notice.

8. GENERAL

8.1 Provide details of any other matter of which, in the licensee's view, the Authority should be aware and attach a copy of the Radio Frequency Spectrum Licence issued to the licensee as Annexure A of FORM C 2:

8.2 Attach a resolution giving the person signing this notice the authority to sign this notice, marked clearly as Annexure A of FORM C 3:

Signed ................................

(LICENSEE)

I certify that this declaration was signed and sworn to before me at ................................ on the ............................ day of ............................ 20...., by the deponent who acknowledged that he/she:

1. knows and understands the contents herein;

2. has no objection to taking the prescribed oath or affirmation; and

3. considers this oath or affirmation to be truthful and binding on his/her conscience.

.........................................

COMMISSIONER OF OATHS

Name:

Capacity:

Address: