I Warrant That All the Details Herein Are Correct

(To be completed by prospective tenant)

Building:______Premises:______

PERSONAL INFORMATION PLEASE PRINT CLEARLY Full name of applicant * Trading name of business If in personal capacity, Identity number * If CC, Company or Organisation, reg. No. * VAT Registration Number Physical address of applicant Code: Postal address of applicant Code: Contact person Telephone  Work numbers  Home  Cellular Facsimile number E-mail address Full name of surety(s) *

Identity number(s) *

Domicilium of each surety (physical address)

Banking details of applicant (for bank referencing – must be a cheque account)  Bank and Branch  Branch code  Account number Banking details of surety (for bank referencing – must be a cheque account)  Bank and Branch  Branch code  Account number PREMISES INFORMATION Size of required premises Proposed occupation date Proposed installation time Proposed lease period Proposed option period Usage / description of business Contact details for Name present or Company previous premises Contact numbers occupied Building occupied Premises number Contact details for Name present or Company previous premises Contact numbers occupied Building occupied Premises number BUILDING INFORMATION What made you consider this site? Why do you believe your business will be successful in this site? What is your marketing strategy for your business? * Please attach the following documents: . Copy of Registration papers or letterhead with number reflected . CC – copy of founding statement showing all members . Company – copy of certificate of registration and name change (if applicable) . Copy of Identity book (if personal capacity) . Surety – copy of all identity books . Copy of company or CC resolution whereby the signatory hereto is authorised to conclude a lease and any amendments thereto

I warrant that all the details herein are correct.

………………………………………………… ………………………………………………… Name (Print) Signature Date: ………………………………………….