Annex A Form

CMA Market Training/Assurance Application

Submitters name and contact details

Company name * Company name is required

Title * Title is required

First name * First name is required

Middle name(s)

Last name * Last name is required

Title/Position * Title/Position is required

Telephone number * Please enter a valid UK Telephone number

Fax Telephone is required

Email address * Please enter a valid Email address

Address line 1 * Address line 1 is required

Address line 2

Address line 3

City * City is required

Postcode * Postcode is required

Licensed Provider Role(s)

Please confirm your intention to operate in the Water Market in Scotland in the following Licensed Provider Role(s)

Please indicate the communication methods:

Low Volume Interface (Training process applies)

High Volume Interface (Assurance process applies)

Please indicate types of provision:

Water Supply

Sewerage Supply

Trade Effluent

Self Supply

Please provide as much of the following information as you are able

Target date for registration of first supply point

How critical is this date to your business?

Preferred dates for CMA training on Low Volume Interface

If operating High Volume Interface, date expected to be ready to start CMA Assurance

I confirm that the information given in this form is complete and correct. Please confirm.

I am duly authorised to sign this form on behalf of the LP. Please confirm.