Applicant’s Name.............................Sign.........................Date.......................... Contact Tel No.......................................... 5. FOR OFFICIAL USE ONLY (i) (ii) (iii) (iv) Case No............................................. Evaluating officers name...........................Sign............................. Approval Recommended/Not Recommended (Delete where not applicable). TAC No./Item No................ Approved/Not Approved/Deferred (Delete where applicable). Form No. 4 Regulation 56 COMMUNICATIONS COMMISSION OF KENYA APPLICATION FOR INDIVIDUAL AUTHORITY TO USE TELECOMMUNICATION TERMINAL EQUIPMENT 1. PARTICULARS OF APPLICANT (i) Full names of Applicant/Company .................................................................................................... P.O. Box.........................Tel No................................................ (ii) Physical Address where the equipment will be used Town....................Road/Street/Estate.................Building..................... (iii) Details of Network in which the equipment is to be connected (i.e. Radio/Data etc)……………………………............................................ (iv) Type of service for which the equipment is intended to be used (e.g. ISP access, Bureau, Residential voicemail, etc) .................................................................................................... (v) Telephone/Circuit number(s) to which the equipment will be connected (where applicable) ........................................................................................................................ 2. DESCRIPTION OF EQUIPMENT ITEM NO TYPE MANUFACTURER MAKE AND MODEL 81 SERIAL NUMBER/IMEI COUNTRY OF ORIGIN