240 Statutory Instruments 15th June, 2012 SCHEDULE (Regulations 6(1), 6(2) and 6(5)) PRESCRIBED FORMS Form I (Regulation 6(1)) (To be completed in triplicate) THE ZAMBIA INFORMATION AND COMMUNICATION TECHNOLOGY AUTHORITY The Information and Communication Technologies Act, 2009 (Act No. 11 of 2009) The Information and Communication Technologies (Universal Access) Regulations, 2010 APPLICATION FOR DESIGNATION AS UNIVERSAL SERVICE ( ) Individual or ( ) class licence Shaded fields for official use only Licence code (Tick as appropriate) Date/Time Information Required Information Provided 1.1. Type of Service 2.2. (a) Name(s) of applicant(s) (b) Type of applicant Individual Tax Payer Identification Number 3.3. (TPIN) 4.4. (a) Nationality 5.5. (b) Identity card (National Registration Card No. or Passport No.) – Attach certified copies (a) Notification address Tel: Fax: E-mail: (b) Information of contact person authorised to represent the Applicant Tel: Fax: E-mail: 6.6. (a) (b) (c) Company name Company address Company registration No. (Attach copies of certificate of registration) 7. 7. Project details (a) Location Proposed launch date District (b) Brief description Company