CM 27 Consent to Act as Director or Officer

Form CM 27

REPUBLIC OF NAMIBIA

BUSINESS AND INTELLECTUAL PROPERTY AUTHORITY - BIPA

COMPANIES ACT 2004

(Section 219) (Regulation 45(1)

CONSENT TO ACT AS DIRECTOR OR OFFICER

AND OTHER DIRECTORSHIPS

Name of company

A. Consent

I hereby consent to my appointment as * director / officer of the above-named company.

I certify that I am not disqualified in terms of sections 225 or 226 of the Companies Act from being a director/officer*.

Signed:

Date:

(To be signed by: Director or officer personally; or the authorised agent on behalf of a director of an external company not resident in Namibia; or the authorised agent of a corporate body.)

*Delete where not applicable.

_________________________________________________________________________________________________________

B. Personal particulars

1. Surname

2. Full forenames

3. Former surname and forenames

Year

Month

Day

4. Identity number or, if not, available, date of birth

5. Date of appointment

6. Residential address

7. Business address

8. Postal address

9. Email address

10. Contact Number

11. Nationality (If not Namibian)

12. Occupation

13. Resident in Namibia (Yes or No)

14. Address of registered office, and registration number, if officer is a corporate body

C. Other Directorships

Attach list hereto

Registration Number of Company