Office use only

Application ref No.

Application for Allocation, Assignment & Reservation of Codes or Blocks of Numbers

Date

1.        Application Type:

e.g. 080, geographic, 086, Mobile. Do not mix types on this application

Application for:

Allocation

Assignment

Reservation

2.        Applicant's Information

Company Name

Company Reg. No.

License No.

Tel

Web Site

Internal Numbering Representative

Name and Surname

Contact No.

Fax

Email

External Numbering Representative (In case of an applicant's using an external adviser e.g. consultant)

Company Name

Name and Surname

Contact No.

Fax

Email

Business Address

Street Address

Suburb

Postal Code

City

Postal Address

P.O. Box

Suburb

Postal Code

3.        Technical Information

Numbering code, block, individual number requested

(Where appropriate second and third preferences should be indicated. N.B. allocation of preferred requested numbering is not guaranteed)

1

2

3

4

5

6

Description of service

(For Individual number requests i.e 080 and 086 include the name of the person or entity requesting the number)

4.        Previous Allocations (Relevant to this application)

Data date:

(if date differs from the date of application

Service Description of Numbers

Quantity (Allocated)

Quantity (Active)

A

Allocated by The Authority

B

Internal Network Services

C

Contract Services

D

Pre-Paid Services

E

Total used for services/network

(B+C+D)

F

Degree of usage ((E/A)*100)

Numbers in Time Window Lock (i.e. numbers in recycling)

Numbers Reserved

4.1        Report on utilization for the past 6 months

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Actual numbers

activated

Actual numbers

churned

I declare that all the information in this Application Form and any the attachments provided are true and correct. I understand that the approval from ICASA for this Application is based on the information as declared in this Application Form. Should any of the information declared, found to be inaccurate or incorrect after approval has been granted to the Applicant, ICASA reserves the right to suspend or revoke such approval without compensation. I declare that the numbers will be used in accordance with the numbering conventions.

Name:

Date:

Signature: