2.

Full registered name of the applicant........................................................................

3.

Trading name of the applicant (if different from the registered name)

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

4.

Registration number of company (if applicable)  .......................................................

5.

Name of mandated representative (if applicable).  Attach documentary proof of mandate given to representative

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

6.

Physical address .......................................................................................................

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

7.

Postal address ..........................................................................................................

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

8.

Telephone number....................................................................................................

9.

Fax number ...............................................................................................................

10.

Email address ............................................................................................................

11.

Details of mandated representative, including:

(a)

designation ............................................................................................

(b)

family name ...........................................................................................

(c)

first name ..............................................................................................

(d)

telephone number .................................................................................

(d)

fax number ............................................................................................

(e)

email address .........................................................................................