Form 200

Sixth Floor, Harbour view Towers, Samora Avenue

P O Box 72175, Dar Es Salaam, Tanzania
TEL: +255-22- 2123850; 2123853; 2123854; 2123856; FAX: +255-22- 2123180
E-mail: info@ewura.go.tz Website: http.// www.ewura.go.tz

LICENCE APPLICATION FORM

PETROLEUM WHOLESALE BUSINESS

For EWURA Use Only

Date Received: File Number:

Time Received: Received by:

IMPORTANT NOTE: Complete this form and return it with all other relevant
enclosures to the Director General at the above address.

In order to avoid unnecessary delays, answer fully all items and submit to
EWURA all of the information required under this application. EWURA will
not process this application until it has been found to be complete.

When completing this form, PRINT USING BLUE OR BLACK INK ONLY.
Where options are given, tick the relevant box. Leave no item unanswered or
un-ticked. If an item seems not applicable to the specific application, you
should indicate with block capitals N/A meaning Not Applicable. You should
ensure that all required documentation is enclosed and that each separate
sheet of information attached to the application corresponds to a specific item
in the application. Where there is a requirement to provide documentation on
a separate sheet, it must be on clean, clear A-4 paper.

PART I: DETAILS OF THE APPLICANT

1. Name of Applicant:

2. Registration Status: (Fill Where Appropriate)

(a) Certificate of Incorporation No…….........................……

(b) Certificate of Compliance No……..........................……..

(c) Business licence Number.......................

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 Form 200

(d) TIN No. ........................................................................

(e) VAT No.………………………...........................…………….

3. Applicant’s Physical and Postal Address:

(a) Physical address:

Street……........….Plot No.............

Block No…..............Building No…….........................

(b) Postal Address: .........................................

(c) Telephone No: ..........................................

(d) Facsimile: ............................Cell Phone................................

(e) E-Mail: ......................................................

4. Legal status of the Applicant:

Partnership
Public Limited Liability Company
Private Limited Liability Company
Parastatal Organization
Government Agency
Cooperative Society
Other (specify)...................................

5. Contact Person:

(a) Name: .....................................................

(b) Title: ........................................................
(c) Physical address:
Street…….......…Plot No….....…Block No…......….
Building No……..............:
(d) Postal Address: .......................................
(e) Telephone Number: ................................
(f) Facsimile: .............................Cell phone: .............................
(g) E-mail: ...................................................

6.
Provide on a Separate Sheet Information Related to the
Applicant:

Shareholding Arrangements
Director (s)
Members of the Board of Directors

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 Form 200

Chief Executive Officer (where applicable)

7. Are any of the persons identified in Item 6 related to or in

business with any existing petroleum service providers in
Tanzania?

Yes No

If yes, provide details.....................................................

.................................................................................................
................................................................................................
................................................. (Use additional Sheet if Necessary).

8. Has the applicant previously been denied a licence or had a

license revoked in Tanzania or in any other country?

If yes, provide details.....................................................

.................................................................................................
................................................................................................
................................................. (Use additional Sheet if Necessary).

No

9. Have any of the persons identified in Item 6 worked in or had

business dealings with any whole seller of petroleum supplier
that has had a licence revoked?

Yes, If yes, provide details..................................................

..............................................................................................
..............................................................................................
.............................................................................................
............................................. (Use additional Sheet if Necessary)
No

10. Has any person identified in Item 6 been convicted of a crime

in Tanzania or any other country?

Yes – If yes, provide details.....................................................

.................................................................................................
................................................................................................
................................................. (Use additional Sheet if Necessary)

No.
11. Has the applicant or any of its parent/holding or affiliate
company been convicted of a crime in Tanzania or in any
other country during the past 3 years?

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 Form 200

Yes – If yes, provide details.....................................................

.................................................................................................
................................................................................................
................................................. (Use additional Sheet if Necessary).

No

12. Does any person identified in Item 6 hold any professional or

downstream petroleum industry qualifications?

Yes – If yes, attach relevant certificates and testimonials

No

13. Has any person identified in Item 6 worked or continues to

work in the petroleum downstream industry (apart from the
applicant company)?

Yes – If yes, attach relevant CVs.

No

14. Fee Amount and Method of Payment:

(a) Amount: TZS……….........…........................................…....

(b) Mode: Cash Cheque Other (specify)........................

(c) Fees Payment Receipt No. (Attach Copy).............................

PART II: APPLICANT’S FINANCIAL DETAILS

15. Provide Extract of the Certified Audited Financial Statements

and Accounts for the 3 years prior to application date.

prior 1 year prior 2 years prior 3 years

16. If the Extracts of the Certified Audited Financial Statements

and Accounts for 3 years are not available, explain why:
.................................................................................................
.................................................................................................
.................................................................................................
.................................................................................................
.................................................................................................
.................................................................................................

17. Attach the Applicant’s Business Plan which shall include:

(a) Applicant’s proposed investment over the next five years.
(if any).

(b) Source of funding for the Proposed Investments.

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 Form 200

18. Describe the applicant’s principal business activity and as

applicable, describe any other business activities in the
petroleum industry which the applicant is currently engaged.
.............................................................................................
.................................................................................................
................................................................................................
..................................................................................................
(Use additional Sheet if Necessary)

PART III: APPLICATION FOR RENEWAL OF A LICENCE

(Note: Questions 23-28 are not applicable to new Applicants)

19. Provide reference number and details for the existing licence.
...............................................................................................
...............................................................................................
................................................................................................
.................................................................................................

20. Has the licensee undergone any material changes (structural,

legal, managerial or related to the services supplied) since its
previous application?

Yes – If yes, provide details..................................................

.................................................................................................
................................................................................................
................................................. (Use additional Sheet if Necessary)

No

21. Fee amount and method of payment:

(a) Mode: Cash Cheque Other (specify)...................

(b) Fees Payment Receipt No. (Attach Copy)...........................

22. Does the applicant seek to vary the existing business or

services provided?

Yes – If yes, provide details...................................................

.................................................................................................
................................................................................................
................................................. (Use additional Sheet if Necessary)

No

23. If the applicant seeks to vary the existing business or services

provided, does the applicant intend to operate different type of

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 Form 200

licensed activity?

Yes –If yes, provide details.....................................................

.................................................................................................
................................................................................................
................................................. (Use additional Sheet if Necessary).

No

24. If the applicant seeks to vary the existing business or services

provided, the applicant should provide details of the
arrangements that have been made to ensure continuity of
service.

Yes – If yes, provide details.....................................................

.................................................................................................
................................................................................................
................................................. (Use additional Sheet if Necessary).

No

PART IV – TECHNICAL INFORMATION

(Note: Questions 29 – 34 are not applicable to Applicants Renewing

existing Licenses)
25. Indicate the purpose(s) of the licence applied:
Domestic
Transit
Other (Specify)......................................

26. Provide a detailed description of a list of ports of entry and exit

through which you intend to import, or export petroleum
products as the case may be.
................................................................................................
................................................................................................
................................................................................................
................................................................................................
............................. (Use additional sheet if necessary)

27. Provide a detailed description of the location and capacity of

the storage facilities:
................................................................................................
................................................................................................
................................................................................................
................................................................................................
............................. (Use additional sheet if necessary)

28. Provide a detailed description of ownership of the storage

facilities which shall include the land to which such facilities
are located and in case of shared facilities the basis for such

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sharing.
................................................................................................
................................................................................................
................................................................................................
................................................................................................
............................. (Use additional sheet if necessary)

29. List and attach evidence of all required permits and consents
issued by relevant authorities:

Land Title No...................................

Other (specify)................................
Environmental Impact Assessment Certificate
Environmental Audit Report

PART V – HEALTH, SAFETY AND ENVIRONMENT (HSE)

30. Attach with this application, as relevant, the following

documents:

EIA certificate
Emergency Response Plan
Fire Certificate from the Fire Authority
OSHA Certificate
Other (Specify).......................................................

PART VI- COMMERCIAL DETAILS

31. Indicate the intended market for the licensed goods and/or
services:

Bulk Supplies
Retail Supplies
Transit
Leasing Assets
Other (specify)...............................

32. Provide a list and attach copies of all relevant:

Contracts or Agreements.
Permits.
Memoranda of understanding (if any) governing commercial
transactions of regulated goods and services.

33. Attach to this application either the existing or the proposed

Customer Service Charter (If any).

PART VII- LIST OF ENCLOSURES

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 Form 200

34. Indicate below and where appropriate the certified copies of,
or extracts from, the following documents the applicant is
providing in this application:

Memorandum and articles of Association

Certificate of compliance
Certified copy of business licence
Copy of Application Fee Receipt
Certified copies of TIN & VAT Certificates
Extracts of the Certified Audited Accounts
Certified copy of Audited accounts
Bankers’ guarantee/letter of comfort/bank statement showing
financial capability
Business Plan
Design and As-built Drawings
Process Flow Diagram
Environmental and Socio Impact Assessment Study Report
Emergency Response Plan
Health and Safety Policy
Approvals and Consents by relevant authorities
Relevant Contracts/Agreements
Current or proposed Customer Service Charter

PART VIII – DECLARATION BY THE APPLICANT

35.
I…...................….. (insert name) being…….............................…
(insert title/position) hereby declare that I am authorized to
make this application on behalf of the applicant and that to the
best of my knowledge the information supplied herein is
correct and that within a reasonable period of time after notice,
I undertake to provide whatever additional information EWURA
may require in order to evaluate this application.

SWORN/AFFIRMED at……………….. ….. )

by the said……………….who is identified to )
me by……………./known to me personally ) …………………………
the latter being known to me personally this ) DECLARANT
………day of ……………20.. )

BEFORE ME:
__________________________
COMMISSIONER FOR OATHS