RETAIL LICENCE ANNUAL INFORMATION (SUBMISSION FORM)

DE 26RETAIL LICENCE ANNUAL INFORMATION (SUBMISSION FORM)PETROLEUM PRODUCTS ACT 120 OF 1977 AS AMENDED - PETROLEUM PRODUCTS SITE AND RETAIL LICENCEREGULATIONS 2006INSTRUCTIONSPLEASE COMPLETE1. READ REGULATIONS BEFORE COMPLETING THIS APPLICATION FORM.2. USE CAPITAL LETTERS AND WHERE APPLICABLE MARK WITH ASITE LICENCE NUMBER/./RETAIL LICENCE NUMBER/SECTION 1: COMPLETE LICENSEE’S PARTICULARSREGISTEREDNAMEIN FULLTRADE NAMEIN FULLENTER DETAILS OF CONTACT MEMBER OF ENTITYTITLEFAMILY NAMEFIRST NAMEIDENTITY NO.SECTION 2: COMPLETE IF THERE IS A CHANGE IN LICENSEE’S PARTICULARSTRADE NAMEIN FULLPOSTALADDRESS OFREGISTEREDOFFICEPOSTAL CODEBUSINESSTEL NO.(INCLUDECODE)i/

MOBILE PHONENUMBERFAX NO.(INCLUDECODE)E-MAILADDRESSSECTION 3: INFORMATION TO BE COMPLETED IN RESPECT OF ANNUAL INFORMATION SUBMISSIONREGISTEREDNAMEIN FULLNAME OF FUEL SUPPLIER (wholesaler / refiner)OIL COMPANY BRAND DISPLAYED/TO BE DISPLAYED ON SITEINDICATE OWNERSHIP BY HISTORICALLY DISADVANTAGED SOUTH AFRICANS (HDSA’s) INPERCENTAGE INDICATE TYPE OF RELATIONSHIP BETWEEN SITE OWNER AND RETAILER (DEALER)(Select one of the following)RETAILER OWNED, RETAILER OPERATED3rd PARTY OWNED, OIL COMPANY LEASED,RETAILER OPERATEDOIL COMPANY OWNED, RETAILER OPERATEDOIL COMPANY TRAINING SITE(Include Wholesale licence number) OTHERIF OTHER(SPECIFY)VOLUMES (LITRES) SOLD IN LAST CALENDAR YEARPETROLDIESELILLUMINATINGPARAFFINii

INDICATE NUMBER OF EMPLOYEES BY RACE, GENDER AND DISABILITYBLACK EMPLOYEES:MALEFEMALEDISABLEDCOLOURED EMPLOYEES:MALEFEMALEDISABLEDINDIAN EMPLOYEES:MALEFEMALEDISABLEDWHITE EMPLOYEES:MALEFEMALEDISABLEDTOTAL NUMBER OF EMPLOYEESSECTION 4: COMPLETE DETAILS ON TRAINING OF LICENSEE’S EMPLOYEESNUMBER OF EMPLOYEES TRAINEDINDICATE TITLE AND QUALIFICATIONS OBTAINED BY EMPLOYEESiii

DOCUMENTS TO BE ATTACHED TO THE SUBMISSION OF ANNUAL INFORMATION FORM1.A declaration that the ownership of the licensed activity has not changed.2.A declaration that a wholesaler, with an exception of a retail activity licensed to a wholesaler fortraining purposes, does not own the licensed retail business.3.Progress and an updated plan in respect of compliance with the objectives of the Charter.4.A declaration that the retail licence is not held directly or indirectly by a licensed wholesaler.iv

DECLARATIONI (full names) . . .hereby declarethat all information provided herein is within my personal knowledge and thata) I am duly authorised to make this declaration;b) I am the designated person responsible for this licence and any conditionsattached thereto;c) I have read and understood the regulations related hereto, with specificreference to Regulation 34 regarding any false declaration; andd) all information provided herein is to the best of my knowledge true andcorrect.Signed at . (place) on this. . day of . . (month) . (year) . .SignatureI certify that the deponent(a)has acknowledged that he/she knows and understands the contents ofthis application form and its annexures, that he/she has no objection totaking the prescribed oath and that he/she considers the oath bindingon his/her conscience; and(b)has in the prescribed manner sworn that the contents of thisapplication form and its annexures are true and signed same beforemeat . .(place)onthis day . (month) . .(year).COMMISSIONER OF OATHSName:Address:Capacity:vof

NOTE: If this application form is completed electronically it must be printed out,signed before a Commissioner of Oaths and submitted with the necessarysupporting documents and submitted to the appropriate regional office usingthe relevant address, mentioned below.GautengWestern CapeKwazulu- NatalPrivate Bag X96Private Bag X9Private Bag X54307PretoriaRoggebaaiDurban000180124000(012) 406 8000(021) 418 3724(031) 335 9647/ 9638Physical AddressPhysical AddressPhysical AddressCorner Paul Kruger & Visagie34 The Terraces BuildingDurban Bay House (3 floor)Visagie Street, 192Riebeek & Bree StreetsAnton Lembede street, 333PretoriaCape TownDurban000180014000Eastern CapeFree StateMpumalangaPrivate Bag X6013Private Bag X 3658Private Bag X7297Port ElizabethWelkomWitbank600094631035(041) 396 3914(057) 391 1300(013) 653 0500Physical AddressPhysical AddressPhysical Address690 Crispin HallThe Strip BuildingProvince BuildingCnr Mount and Diaz RoadStateway & Bok Street, 314Cnr Paul Kruger & Botha AvenuePort ElizabethWelkomWitbank600094601035North WestNorthern CapeLimpopoPrivate Bag XA1Private Bag X6093Private Bag X9712KlerksdorpKimberleyPolokwane257083010699(018) 464 2460(053) 807 1710(015) 287 4720Physical AddressPhysical AddressPhysical AddressVaal University of Technology65 Phakamile Mabija StreetBroll BuildingBuildingPerm BuildingDorp Street 101Cnr Voortrekker & MargaretaNorthern CapePolokwanePrinsloo streetKimberley0699Klerksdorp83002570vird

ANNEXURE B: LICENCE FEESWholesale licence feeR 1000Annual wholesale licence feeR 500Duplicate licence feeR 500Temporary licence feeR 500Licence amendment feeR 500Payment must be deposited into the following relevant regional account closestto the region where the application is lodged –Bank: NedbankAccount holder: Department of EnergyInclude your reference number, which will be provided by the Controller, on thedeposit slip.Account Holder NameAccount NumberBranch codeDepartment of Energy - GP1454 117 76114 54 05Department of Energy - KZN1454 117 78814 54 05Department of Energy - NW1454 117 79614 54 05Department of Energy - WC1454 117 81814 54 05Department of Energy - MP1454 117 82614 54 05Department of Energy - FS1454 117 83414 54 05Department of Energy - EC1454 117 84214 54 05Department of Energy – LP1454 117 85014 54 05Department of Energy - NC1454 117 86914 54 05viiBranch NameCorporate ClientServices, JohannesburgCorporate ClientServices, JohannesburgCorporate ClientServices, JohannesburgCorporate ClientServices, JohannesburgCorporate ClientServices, JohannesburgCorporate ClientServices, JohannesburgCorporate ClientServices, JohannesburgCorporate ClientServices, JohannesburgCorporate ClientServices, Johannesburg

1. read regulations before completing this application form. site licence number 2. use capital letters and where applicable mark with a . retail licence number retail licence annual information (submission form) petroleum products act 120 of 1977 as amended - petroleum products site and retail licence regulations 2006 / /