Schedule 5
CLASS LICENCE(S) APPLICATION FORM – TYPE A SERVICE
(Regulation 9(a))
Under section [32] of the Telecommunications Act, Cap. 8.11
[ECTEL Member State]
Name of Applicant: _________________________________________
Type of Application: New Application
Application to Modify/Amend an Existing Licence
Application to Renew Licence
Please tick ( / ) the licence that is being applied for:
Value-Added Services
Internet Services Provision (1-5 Units)
Internet Services Provision (6-25 Units)
International Simple Voice Resale
Short Term (< 15 days)
Audio-text Services
Video-text Services
National Telecommunications Regulatory Commission
[NTRC ADDRESS]
Guidance Notes
• Three (3) completed application forms are required to be submitted for each type of licence applied for. Each application should carry an original signature.
• A non-refundable application fee of five hundred (EC$500.00) Eastern Caribbean dollars per licence application is payable to the National Telecommunications Regulatory Commission, [ECTEL Member State].
• Applications are to be submitted in an envelope marked “Telecommunications Class Licence Application” addressed to the Secretary, National Telecommunications Regulatory Commission, [NTRC ADDRESS].
• Incomplete applications will not be accepted by the Commission
• The contents of this application form do not constitute legal advice. Applicants are urged to seek legal advice with respect to any matter pertaining to the telecommunications licensing regime.
• For questions or sections that are not applicable, write “NOT APPLICABLE” in bold or in print.
• 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.
Part I –The applicant
1.1 Contact Details
Registered Business address
Postal address
Designated contact person: _________________ Position: __________
Telephone number
Fax number
Email address
Website:
1.2 Business Details
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1.2.1 State whether the applicant is a company, partnership, joint venture or other body
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______________________________________________
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______________________________________________
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1.2.2 If the applicant is a company, partnership, joint venture or other body please give the name(s), private address (es) and nationality of each of the current directors, company secretary, or partners:
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Name & Nationality Address
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______________________________________________
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______________________________________________
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1.2.3 If not incorporated in [ECTEL Member State], please provide any registration number, which the Registry of Companies in [ECTEL Member State] may have issued.
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______________________________________________
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In support of 1.2.3 above, please provide certified copies of the Certificate and Memorandum 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
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______________________________________________
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______________________________________________
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]?
YES NO
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If NO, proceed to question 1.3.2
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If YES, was the licence granted?
YES NO
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If YES, under what Act(s) was/were the licence(s) granted?
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(Provide the details of each such licence)
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______________________________________________
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______________________________________________
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If NO, on what grounds was/were the licence(s) refused?
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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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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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If YES, on what grounds was the licence revoked?
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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?
YES NO
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If YES, state reasons
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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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If YES, state which other countries
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______________________________________________
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______________________________________________
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1.3.6 Has the applicant or any Affiliate been refused a telecommunications licence mentioned in question 1.3.5 in any country, or had a licence revoked?
YES NO
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If YES, state the grounds for refusal or revocation
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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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If YES, state the other name of the business
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______________________________________________
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______________________________________________
2. PART II - APPLICANT'S BUSINESS AND PROPOSED SERVICE(S)
2.1 Financial Information and Business Plan
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2.1.1 Please provide a business plan covering a five (5) year span outlining:
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2.1.2 Details of the market studies identifying the target market(s) to be served by the proposed operations, perceived market risks and proposed strategies for mitigation of risks;
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2.1.3 Statement showing capital cost of the operation
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2.1.4 Forecast Balance Sheets, Income Statements and Statements of Cash Flow for each of the five (5) years following the commencement of operation;
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2.1.5 Detailed assumptions underlying all aspects of the projections made;
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2.1.6 (Evidence of the availability of financial resources to establish and maintain the proposed service. (Such evidence might include letters of commitment from financial institutions, and a statement of net worth supported by an affidavit/statutory declaration)
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2.1.7 If the applicant is a going concern, please provide Approved, Audited Balance Sheets and Income Statements for the three (3) most recent years.
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2.1.8 If the applicant is a member of an operating group, please provide Approved, Audited Balance Sheets and Income Statements of its parent company or consolidated group, for the three (3) most recent years.
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2.1.9 Please provide a diagrammatic representation of the applicant's group structure
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2.1.10 Evidence as to whether the applicant, or any of its related entities, hold more than 5% in the equity of any other licensed telecommunications provider in the OECS
YES NO
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If YES, give the name(s) of provider(s) and percentage shareholding
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______________________________________________
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______________________________________________
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2.1.11 Has any member of the applicant's managerial staff been bankrupt, or filed for bankruptcy?
YES NO
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If the answer is YES, please attach a certified copy of the discharge.
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2.1.12 Has any member of the applicant's managerial staff been a director of a company, which has become insolvent or has filed bankruptcy proceedings?
YES NO
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If the answer is YES, please provide the name of the company.
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______________________________________________
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______________________________________________
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2.1.13 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 violence or dishonesty, 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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If YES, provide details
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______________________________________________
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______________________________________________
2.2 Applicant's Current Activities
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2.2.1 Please provide answers to the following questions in relation to:
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(a) the applicant's activities in the OECS;
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(b) the applicant's activities elsewhere in the Caribbean; and (c) the applicant's activities elsewhere in the world.
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2.2.2 Please provide a summary of any infrastructure the applicant has in place, including radio-based infrastructure.
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2.2.3 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 authorisation.
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2.2.4 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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2.2.5 Please provide details of current contracts with all classes of customers, as well as copies of all such contracts.
2.3 Applicant's Proposed Activities
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2.3.1 Please provide a summary of any infrastructure the applicant is planning to put in place within the next three (3) 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).
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2.3.3 Please provide a description of each proposed service, which schematic drawings as necessary, and 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.
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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].
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2 This declaration must be signed:
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(a) in the case of an individual, by the person in whose name the application is made;
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(b) in the case of a sole proprietorship, by the sole proprietor, or
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(c) in the case of a partnership, by a partner; or
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(d) in the case of a company or other body corporate, by a director, company secretary or other authorised officer signed
3 PART III - DECLARATION2
(Delete the option that does NOT apply)
On behalf of the applicant, I declare that the information provided is accurate and complete in all respects.
Signed:
_________________________________________
Full name signatory: Position held:
_________________________________________
_________________________________________
Date: _____________________