Annex B Form

Self-Certification Form

Signatory name and contact details

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

Email address * Please enter a valid Email address

Witness name and contact details

Title * Title is required

First name * First name is required

Middle name(s)

Last name * Last name is required

Address line 1 * Address line 1 is required

Address line 2

Address line 3

City * City is required

Postcode * Postcode is required

Services

Please specify the service this declaration relates to.

Service * Service is required

On behalf of the licensed Provider, I declare that the Licensed Provider:

Understands its obligations under the Market Code, Code Subsidiary Documents and the market framework generally; Please confirm.

Acknowledges that the Licensed Provider is bound by the Performance Standards and is liable for Performance Standard Charges in accordance with the Market Code; Please confirm.

Has undertaken training provided by the Central Market Agency on the operation of the Low Volume Interface; and Please confirm.

Can operate the Low Volume Interface for the Central Systems; Please confirm.

Acknowledges that the Commission, the Central Market Agency and any of their agents will not be held responsible for any difficulty that the Licensed Provider may encounter using the Low Volume Interface. Please confirm.

Licensed provider name * Licensed provider name is required

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.