Application Form C for Removal of Name from the Register

FORM C – REMOVAL OF NAME FROM THE REGISTER

PAC Act 2011

FORM C: REMOVAL OF NAME FROM THE REGISTER
SECTION A: PARTICULARS OF APPLICANT
Application Form for Removal of Name from the Register
(To be completed in block letters)
Family Name : …………………………………………………………………………………………………………………………………….
Other Names : …………………………………………………………………………………………………………………………………….
Gender : M  F  Citizenship : …………………………………………………………………………..
(In addition to the Mauritian nationality)
Country & City of Birth : …………………………………………………………………………………………………………………………
Date of Birth (DD/MM/YYYY): ………… / ………… /……………
Identity Card: ……………………………………………………………. Passport No: ………………………………………
Country & City of issue: …………………………………………………………….. Date (D/M/Y): …………………………………
PAC Registration Number: ………..
CONTACT DETAILS
Residential Address: ………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………
Tel: ……………………………………. Mobile: …………………………… E-mail………………………………………………………..
Regular Business Name & Address: ………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………
Tel: ……………………………………. Fax: …………………………………. E-mail: ………………………………………………………
SECTION B: REASON FOR REQUEST FOR REMOVAL OF NAME FROM THE REGISTER
Reason: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

SECTION C: DECLARATION TO BE SIGNED BY APPLICANT
To: The Registrar
Professional Architects’ Council, Mauritius
I, the undersigned, hereby apply for my name and other particulars as a professional architect
to be removed from the register of professional architects, and

1. I declare that all particulars given by me in respect of the present application are true,
2. I declare to have taken good note of Section 20, 21 & 22 of the PAC Act 2011.
  Signature: ……………………………………………… Date (DD/MM/YYYY): …………/ ….………/ …………