ake, ) enel gy Department Energy REPUBLIC OF SOUTH AFRICA DE 25 ‘WHOLESALE LICENCE ANNUAL INFORMATION (SUBMISSION FORM) PETROLEUM PRODUCTS ACT 120 OF 1977 AS AMENDED - PETROLEUM PRODUCTS WHOLESALE REGULATIONS 2006 INSTRUCTIONS {READ THE REGULATIONS BEFORE COMPLETING THIS APPLICATION FORM. ‘WHERE APPLICABLE MARK wr ant,PLEASE COMPLETE. WHOLESALE LICENCE NUMBER SECTION 1: COMPLETE LICENSEE'S DETAILS REGISTERED NAME pie is|r| |r |e je |e|r) rie INFULL ele olslelelris “TRADE NAME INFULL alals loli |r ene ENTER DETAILS OF CONTACT MEMBER OF ENTITY me wR Fauiyname [Ml A)P [IIL] 1] KA Firstname | sie|p | ml) a wie wenrryno. | 8f4]4)4j1jolsis lot ole ‘SECTION 2: COMPLETE IF THERE IS A CHANGE IN LICENSEE'S PARTICULARS. “TRADE NAME, INFULL PosTat, ‘ADDRESS OF REGISTERED OFFICE POSTAL CODE BUSINESS TELNO. (NGLUDE cope)MOBILE PHONE NUMBER FAX NO. INCLUDE CODE) EMAIL ‘ADDRESS ‘SECTION 3: COMPLETE ONLY IF THERE HAS BE (IN GASE OF INDIVIDUAL, ENTER APPLICANTS mE I DETAILS) |EEN A CHANGE OF DESIGNATED PERSON OF THE ENTITY FAMILY NAME FIRST NAME IDENTITY No. ‘SECTION 4: INFORMATION TO BE J COMPLETED IN RESPECT OF VOLL THE REPUBLIC OF SOUTH AFRICA IN THE LAS sT CALENDAR YEAR, LUMES (LITRES) PURCHASED WITHIN, PETROL DIESEL ILLUMINATING PARAFFIN AVIATION ‘GASOLINE LUIFIED PETROLEUM GAS JET FUEL BIOFUELSVOLUMES (LITRES) SOLD WITHIN THE REPUBLIC OF SOUTH AFRICA IN LAST CALENDAR YEAR PETROL o v DIESEL ILLUMINATING solo PARAFFIN Te AVIATION Li GASOLINE LUIFIED 0 PETROLEUM AS, JETFUEL, 0 BIOFUELS INDICATE NUMBER OF EMPLOYEES BY RACE, GENDER AND DISABILITY 0 | of6 BLACK EMPLOYEES: COLOURED EMPLOYEES: MALE FEMALE DISABLED MALE FEMALE DISABLEDINDIAN EMPLOYEES: MALE 9% FEMALE % DISABLED 0% WHITE EMPLOYEES: MALE | | FEMALE 096 DISABLED 0% ‘TOTAL NUMBER OF EMPLOYEES ° INDICATE OWNERS PERCENTAGE re DISADVANTAGED SOUTH AFRICANS (HDSA’e) IN % 1. Addeciaration by the licensee that the ownership ofthe licensed activity has not changed. 2. The volumes of each prescribed petroleum products purchased and sold outside of the Republic of South Africa. 3. A doctaration by the applicant stating thatthe applicants in compliance with all national provincial and focal government legal requirements 4, The volumes of each prescribed petroleum products purchased and sold outside of the Republic of South Attica. 5. Aprogress and an updated plan in the respect of complying with the objectives of the Charter. 8. Areport on the training and the number and tite ofthe qualifications obtained by leamers employed by the lcensed wholesaler. ivDECLARATION | (full names) SEPHIWE MOSES MAFILIKA hereby deciare that all information provided herein is. within my personal knowledge and that- a) 1am duly authorised to make this dectaration; b) am the designated person responsible for this licence and any conditions attached thereto; ©) Ihave read and understood the regulations related hereto, with specific reference to Regulation 25 regarding any false declaration; and 4) all information provided herein is to the best of my knowledge true and correct. Signed at Rustenburg, Mogwase (place) on this 13! Day of February (month) 2025 (year) Se, \ certify that the deponent- (a) has acknowledged that he/she knows and understands the contents of this application form and its annexures, that he/she has no objection to taking the prescribed oath and that he/she considers the oath binding on his/her conscience; and {b) has in the prescribed manner swom that the contents of this application form and its annexures are true and signed same before me at Rustenburg, Mogwase (place) on this 13 day of February (month) 2025 (year). votes, ye COMMISSIONER OF OAT! Name:_ Suture weokwe le GY Address: “ACEUIGSG Shoko Woed+ Capacity: GAGE CUNOTE: If this application form is completed electronically it must be printed out, signed before a Commissioner of Oaths and submitted with the necessary supporting documents and submitted to the appropriate regional office using ‘the relevant address, mentioned below, [ Gauteng, im Cape Private Bag X19 Private Bag XO Private Bag X54307 Arcadia Roggebaai Durban 0007 8012 4000 (012) 444 4444 (021) 427 1049/ 1017 (031) 335 9647/ 9638, Physical Address Physical Address hysical Addres: Travenna Campus Atterbury House (10 floor) | Durban Bay House (3" floor) Meingjies and Schoeman Street, 75 | Riobeck Street, & ‘Anton Lembede stroat, 333 Sunnyside Capo Town Durban Pretoria 8001 4000 0007 | Eastern Cape Mpumalanga Private Bag X6076 Private Bag X33 Privale Bag X7297 Port Elizabeth Welkom Witbank ‘8000 9463 1035 (041) 306 3910 (087) 391 1300 (013) 656 1448 Physical Address Physical Address hysical Address Easter cape Mount Croix The Trip Building Province Building ‘Vaal University of Technology Building Car Voortrekker & Margareta, Prinsioo street Klerksdorp 2570 Liberty Building (1% Noor) Cuny Street, 29-31 Northern Cape Kimberley 8300 Cnr Mount and Diez Road Statoway & Bok Street, 314 | Cnr Paul Kruger & Botha Avenue Port Elizabeth Welkom Witbank 6000 9460 1035 North West Norther Cape Timpope Private Bag XA1 Private Bag X6003 Private Bag X9467 Klerksdorp Kimberley Polokwane 2570 8300 0699 (018) 487 9867 (053) 807 1782 (018) 287 4727 Physical Addi Physical Address Physical Addi Dorp Street 101 Polokwane 0699