Schedule 3
(Regulation 6(1)(a))
APPLICATION FORM FOR AN INDIVIDUAL LICENCE
Under section 29 of the Telecommunications Act, Cap. 8.11
SAINT LUCIA
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Name of Applicant…………………………................................................……………
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Type of Application New Application
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Application to Modify/Amend an Existing Licence
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Application to Renew Licence
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Please tick as appropriate
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Fixed Mobile Telecommunications Licence
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Public Mobile Telecommunication Licence
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Public Radio Paging Licence
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National Telecommunications Regulatory Commission
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[Insert Address]
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[ECTEL Member State]
Guidance Notes
• Only one licence shall be applied for on each application form. A person wishing to apply for more than one licence shall be required to use the requisite number of forms.
• Please note that this form may also be used for an application to modify an existing licence under section 39 of the Telecommunications Act, Cap 8.11.
• [3] copies of the completed application form should be submitted in an envelope clearly marked “Telecommunications Individual Licence Application” addressed to Secretary, National Telecommunications Regulatory Commission, [Insert Address], [ECTEL Member State].
• For a renewal of licence please attach a copy of the present or existing licence to the completed application form.
• The completed application form must be accompanied by a fee of one thousand Eastern Caribbean dollars (EC$1000) for each licence applied for, payable to the National Telecommunications Regulatory Commission, [ECTEL Member State].
• For questions or sections, which are not applicable, write or type “NOT APPLICABLE” in bold or print.
• Incomplete applications or applications with conditional statements may be summarily rejected.
• Please indicate which, if any, information provided by the applicant in this application is to be considered confidential.
• Please note that any word, phrase or expression used herein shall have the same meaning as it has in the Telecommunications Act, Cap 8.11.
• The contents of this application form do not constitute legal advice. Applicants are urged to seek independent confirmation and professional advice with respect to any matter pertaining to the telecommunications licensing regime.
1. Part I -THE APPLICANT
(Please complete fully in type or block letters)
1.1 Contact Details
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1.1.1 Name and business address of applicant
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1.1.2 Postal address (if different from above)
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1.1.3 Designated contact person
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1.1.4 Telephone number
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1.1.5 Fax number
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1.1.6 E-mail address (if available)
1.2. Business Details
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1.2.1 If the applicant is a company, partnership, or other body corporate please give the name(s) and private address of each of the current directors, company secretary, or partners:
Name Address
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______________________________________________
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______________________________________________
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______________________________________________
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______________________________________________
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1.2.2 State the name under which applicant proposes to trade, and registered office address if different to above:
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______________________________________________
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______________________________________________
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______________________________________________
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1.2.3 In the case of a company or other body corporate, please provide copies of the company's/entity's articles of incorporation.
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1.2.4 Address in [ECTEL Member State] for service of process or other notices (in case of overseas applicant)1
1.3 History of the Applicant
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1.3.1 Has the applicant ever applied for a licence or registration under any Act in [ECTEL Member State] and been refused?
[YES] [NO]
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______________________________________________
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______________________________________________
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______________________________________________
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1.3.2 Has the applicant ever been licensed under the Telecommunications Act, Cap. 8.11?
[YES] [NO]
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______________________________________________
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______________________________________________
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______________________________________________
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1.3.3 If the answer to question 1.3.2 is YES, has any such licence been revoked?
[YES] [NO]
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______________________________________________
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______________________________________________
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______________________________________________
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1.3.4 Has any Affiliate of the applicant previously been granted a licence under the Telecommunications Act, Cap. 8.11 which was revoked?
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Where the applicant is located overseas, the application must include an address for service of process and any other notice in [ECTEL Member State]
[YES] [NO]
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______________________________________________
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______________________________________________
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1.3.5 Is the applicant the holder of a telecommunications licence in any other country?
[YES] [NO]
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______________________________________________
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______________________________________________
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______________________________________________
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1.3.6 Has the applicant or any Affiliate been refused a licence mentioned in question 1.3.5 above, or had a licence revoked?
[YES] [NO]
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______________________________________________
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______________________________________________
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______________________________________________
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1.3.7 Has the applicant operated under or carried on business under any name other than the name in this application?
[YES] [NO]
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______________________________________________
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______________________________________________
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______________________________________________
2. PART II - APPLICANT'S BUSINESS AND PROPOSED NETWORK AND/OR SERVICE(S)
2.1 Financial Information and Business Plan
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2.1.1 Please provide a business plan. The plan should outline any major assumptions used and should cover a period of at least [five] years. The information provided should include:
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• Source of funds including amount and type of funding supported by independent confirmation as appropriate including by official letter of credit from a financial institution, or affidavit with supporting official bank statements;
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• Proforma financial statements for [five] years to include balance sheet, statement of cash flow and income statements; and
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• Market forecasts.
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2.1.2 For a going concern, please provide Audited Financial Reports or certified financial statements for the last three years in respect of the Company on whose behalf the application is being submitted.
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2.1.3 Please provide a diagrammatic representation of the applicant's group structure, including the percentage of shares held. Please indicate which affiliates have, or intend to apply for, other telecommunications licences.
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2.1.4 Does the applicant have any shareholdings of over 5% in any other licensed telecommunications provider in the OECS?
[YES] [NO]
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______________________________________________
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______________________________________________
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2.1.5 Does the applicant have any other trading activities in or outside the telecommunications market?
[YES] [NO]
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______________________________________________
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______________________________________________
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If the answer is YES, please provide details of any arrangements made to ensure no cross-subsidization between the applicants:
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(a) telecommunications and non-telecommunications activities
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(b) wholesale and retail activities
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(c) telecommunications equipment production or supply and other telecommunications activities.
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2.1.6 Please provide brief résumés of key managerial staff, indicating relevant prior experience, qualifications and other sources of expertise as appropriate, and also explain what technical resources exist to help complete plans.
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2.1.7 Has any member of the applicant's managerial staff been bankrupt, or been a director of a company which has become insolvent?
[YES] [NO]
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______________________________________________
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______________________________________________
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If the answer is YES, please attach a certified copy of the discharge.
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2.1.8 Has the applicant or any member of the applicant's managerial staff ever been the defendant or respondent in any proceedings in any court in any jurisdiction involving dishonesty, fraud, theft or violence, or is the applicant or any member of the applicant's managerial staff currently the subject of a charge or indictment under the law of any country for [contravention of any law or for] any conduct involving dishonesty, fraud, theft or violence?
[YES] [NO]
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______________________________________________
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______________________________________________
2.2 Applicant's Current Activities
Please provide answers to the following questions in relation to (a) the applicant's activities in the OECS; (b) the applicant's activities elsewhere in the Caribbean; and (c) the applicant's activities elsewhere in the world.
Networks
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2.2.1 Please provide a summary of the infrastructure that the applicant has in place, including radio-based infrastructure.
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2.2.2 If the applicant is using radio frequency spectrum, please provide details of the frequency authorisations held, including the number of frequency authorisations and the reference number of each Frequency Authorization
Services
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2.2.3 Please provide details of the products and services being provided by the applicant and the terms (including prices) on which they are available. In particular, please provide details on the number of customers and lines installed.
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2.2.4 Please provide details of current contracts with all classes of customers, as well as copies of all such contracts.
Licence obligations
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2.2.5 Please provide details of how the applicant currently complies with the following obligations in relation to its existing networks and/or services (where relevant):
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(a) any build-out obligations
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(b) any public payphone obligations
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(c) any obligations to provide access to emergency services
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(d) any universal service obligations
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(e) any customer obligations, including the provision of information services, quality of service obligations, and dispute resolution procedures
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(f) any interconnection or facility-sharing obligations, including details of the cost accounting system to be adopted by the applicant in order to allow unbundling of interconnection charges and the calculation of component costs
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(g) any leased line and resale obligations
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(h) any privacy and confidentiality obligations
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(i) any non-discrimination obligations
2.3 Applicant's Proposed Activities
Networks
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2.3.1 Please provide a summary of the infrastructure that the applicant is planning to put in place within the next three years, including radio based infrastructure.
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2.3.2 If the applicant is planning to use radio frequency spectrum, please indicate whether an application has been submitted for a frequency authorisation and provide details (copies may be enclosed if preferred).
Services
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2.3.3 Please provide a description of each proposed service, including details on the following:
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(a) all technical aspects of the services (including equipment)
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(b) how access to the service is to be provided (e.g. indirect access, direct access, leased lines, etc.)
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(c) targeted customer base, including number of customers targeted
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2.3.4 Please provide details of any proposed supply relationships in respect of the proposed network and/or services.
Licence obligation
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2.3.5 Please provide details of how the applicant proposes to comply with the following obligations in relation to its proposed networks and/or services (where relevant):
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(a) any build-out obligations
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(b) any public payphone obligations
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(c) any obligations to provide access to emergency services
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(d) any universal service obligations
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(e) any customer obligations, including the provision of information services, quality of service obligations, and dispute resolution procedures
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(f) any interconnection or facility-sharing obligations, including details of the cost accounting system to be adopted by the applicant in order to allow unbundling of interconnection charges and the calculation of component costs
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(g) any leased line and resale obligations
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(h) any privacy and confidentiality obligations
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(i) any non-discrimination obligations
3. PART III - DECLARATION2
On behalf of the applicant, I declare that the information provided by me on behalf of the applicant is accurate and complete in all respects.
Signed:
_________________________________________
Full name of signatory: Post held:
_________________________________________
Date:
_________________________________________
2___________________
2 This declaration must be signed:
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(i) in the case of an individual, by the person in whose name the application is made;
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(ii) in the case of a sole proprietorship, by the sole proprietor, or
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(iii) in the case of a partnership, by a partner; or
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(iv) in the case of a company or other body corporate, by a director of the company or other body corporate