No. 41970   79 STAATSKOERANT, 12 OKTOBER 2018 home affairs u DHA -1774 REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS Annexure 21 Department: Home Affairs APPLICATION REPUBLIC OF SOUTH AFRICAFOR DESIGNATION AS FUNERAL UNDERTAKER y [Births and Deaths Registration Act 51 of 1992] [Section 22A(1)] To be completed by the Applicant. The form must be completed in BLACK INK with BLOCK LETTERS. Applications that are not legible shall not be accepted. A. PARTICULARS OF BUSINESS OWNER (must be the Applicant) Identity number Y Date of birth Y Y Y M M D D Surname Previous / Maiden Surname Left thumbprint of applicant Forenames in full Address Street Town / Village Code Province Telephone number Cell phone number E-mail address Fax B. PARTICULARS OF BUSINESS Name of business / funeral parlour Business Reg. No (CIPC) SARS Reg. No Address Street Town / Village Province Telephone number Code Cell phone number Fax E-mail address C. DECLARATION BY BUSINESS OWNER I, ____________________________________________________ hereby declare that the information provided in this form is true and correct. I understand that giving false information is an offence which is punishable in terms of section 31 of the Act. Date signed Signature Y Y Y Y M D. FOR OFFICIAL USE ONLY - OFFICE OF ORIGIN M D D DOCUMENTS SUBMITTED: APPLICATION RECEIVED BY: Surname Copy of business owner's Identity document Forenames in full Certificate of competency from municipality Copy of SARS registration Persal number Date Y Y Y Y M M D D Office stamp Copy of CIPC certificate Copy of registration with Federation / Association of Funeral Undertakers Signature E. Online verification performed on Business Owner and printout attached Business owner Surname Forenames in full Persal number Signature Date F. APPLICATION VERIFIED: Y Y Y Y M M Approved STATUS D D Rejected I , ______________________________________________________________________ hereby declare that I have received and verified the application and have approved / rejected* the application. (* delete whichever is not applicable). Allocated Designation Number: Official Stamp Surname Forenames in full Persal number Signature Date Y Y Y Y M M D D This gazette is also available free online at www.gpwonline.co.za