<p> W12/774</p><p>Application Form for Natural Gas Retail Supplier Licence </p><p>This Application Form is to be used when applying for either an electricity retail supplier’s licence under the Electricity Supply Act 1995 or a natural gas retail supplier’s authorisation under the Gas Supply Act 1996.1 </p><p>You should complete this form according to the instructions outlined in the Guide for Prospective NSW Electricity and Natural Gas Retail Suppliers (the Guide). The Guide and the Application Form are available on the Independent Pricing and Regulatory Tribunal’s website, www.ipart.nsw.gov.au. </p><p>Any questions should be directed to the Program Manager, Energy Compliance on email, [email protected], or telephone, (02) 9113 7732. </p><p>1 For convenience the term, “Licence” will be used throughout this guide to describe both the natural gas retail supplier’s authorisation and electricity retail supplier’s licence. </p><p>1 Application Form</p><p>Licence Information</p><p>Electricity Retail Supplier Licence [double click on box to check]</p><p>Natural Gas Retail Supplier Authorisation [double click on box to check]</p><p>Identity of the Applicant</p><p>To obtain an electricity or natural gas retail supplier licence, an applicant must be a distinct legal identity. The legal entities envisaged by the Tribunal include:  A company recognised under Australian corporation law, or a corporation or statutory authority owned by an Australian government (Commonwealth, State or Territory).  A natural person.  A legal entity as trustee.  A partnership or joint ventures.</p><p>Applicants must be able to demonstrate their suitability regarding the assessment criteria. A licence is only issued in the name of an applicant. </p><p>1. Applicant</p><p>Insert name of applicant</p><p>2. Type of entity</p><p>Insert description of entity and attach copy of relevant registration instrument (eg. ASIC certificate of company registration).</p><p>3. Registered Office</p><p>Insert address of registered office.</p><p>4. Contact Details</p><p>Provide the proposed Licence Holders' business address. Provide the proposed Licence Holders' postal address (if different). Provide the proposed Licence Holders' contact details including telephone, facsimile and e-mail.</p><p>5. Nominated Contact</p><p>2 Provide the name and contact details of an individual to whom the Secretariat can direct enquiries and correspondence about the Licence Application.</p><p>6. Management and Board Details</p><p>Provide full names, dates of birth and residential addresses of the Chief Executive Officer, Directors or Partners of the applicant to assist ATSIC and ITSA searches. Personal details will be kept confidential.</p><p>7. Supply Details</p><p>Provide details of the type of customer that the proposed Licence Holder intends to supply in the next twelve months (small retail / large retail / both).</p><p>8. Market Entry Details</p><p>Provide details of the timing of the proposed Licence Holder's entry into the NSW electricity or natural gas retail supply market.</p><p>Information Addressing the Assessment Criteria</p><p>1. Fit and Proper</p><p>Attach a Statutory Declaration from the nominated representatives of the applicant to the effect that they are not, or would not be, disqualified under the Corporations Act 2001 (Commonwealth) from the management of corporations.</p><p>2. Financial Capacity</p><p>Attach a Statutory Declaration from the nominated representative of the applicant to the effect that the applicant is in a position to meet the applicable financial and prudential requirements, DNSP or reticulator credit support and that they are not aware of any factor which would affect the ability of the applicant to securely finance the activities to be performed under the licence over the following 12 months.</p><p>3. Technical and Operational Capacity</p><p>3 Attach the following: A compliance plan outlining how all applicable licensing obligations will be met. Sign off from the applicant’s General Counsel or Solicitor confirming that its customer contracts and contractual information for supply to small retail customers meet all statutory requirements. Details of any arrangements an applicant has with companies to provide services that attract licensing obligations. Details of the proposed Licence Holder’s, or its principal officers/agents experience in the energy sector or other relevant industry. Details of energy licences held in other jurisdictions.</p><p>Acknowledgement</p><p>The applicant acknowledges that the Tribunal may:  seek information from other regulators about compliance with licences it holds in other jurisdictions;  engage an information broker to conduct searches of the Australian Security & Investments Commission (ASIC) and Insolvency and Trustee Service Australia (ITSA) registers and websites; and  place this application form on the Tribunal’s website (with the exception of personal details of appropriate persons providing statutory declarations).</p><p>4</p>