# Proxy Consent and Authorisation Certificate

**Free Me South Africa (Pty) Ltd**
Registration Number: 2025/384802/07
Version 3.0 | Effective Date: 24 August 2026

*This document forms part of the statutory document bundle submitted to the National Gambling Board together with NGB Form 1/1. It is executed simultaneously with the NGB Form 1/1 and the FMSA Self-Exclusion Submission Certificate under the Mirror Signature Doctrine. The applicant's single electronic signature applied in Step 3 of the SE registration flow simultaneously executes all three documents in this bundle.*

*This certificate constitutes a written mandate, a POPIA consent instrument, and an ECTA Section 25 attribution record. It is binding on the Applicant from the moment of electronic execution and is irrevocable for the submission and follow-up period described below.*

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## Part A: Identity of the Parties

### A.1 The Appointing Party (the "Applicant")

This certificate is executed by the person who has completed and signed NGB Form 1/1 via the FMSA Self-Exclusion Platform. The Applicant's full name, South African Identity Number, contact details, and physical descriptors are recorded in Part A of NGB Form 1/1 (attached to this bundle) and are incorporated into this certificate by reference.

By executing this certificate, the Applicant confirms that:
1. They are the person identified in the accompanying NGB Form 1/1;
2. They are applying for self-exclusion voluntarily and of their own free will;
3. They are 18 years of age or older;
4. The information provided in NGB Form 1/1 is true, accurate, and complete to the best of their knowledge.

### A.2 The Appointed Representative (the "Representative")

| Detail | Information |
|---|---|
| Full legal name | Free Me South Africa (Pty) Ltd |
| Registration number | 2025/384802/07 |
| Address | Republic of South Africa |
| Email | exclusions@freemesouthafrica.co.za |
| WhatsApp | +27 66 215 4063 |
| Website | www.freemesouthafrica.co.za |
| Founder and Chief Executive Officer | Pierre van Staden |
| Information Officer (POPIA) | Pierre van Staden |

---

## Part B: Appointment and Grant of Mandate

I, the Applicant (as identified in Part A and in the accompanying NGB Form 1/1), hereby appoint Free Me South Africa (Pty) Ltd ("FMSA") as my authorised representative under common-law mandate and in accordance with Section 25 of the Electronic Communications and Transactions Act 25 of 2002 ("ECTA"), for the purposes and with the authority set out in this certificate.

### B.1 Nature of the Appointment

This appointment is:
- **Written:** constituted in writing as required by common law for a mandate involving the submission of statutory instruments;
- **Specific:** limited to the purposes and scope described in Part C and subject to the exclusions in Part C.5;
- **Irrevocable** for the submission and follow-up period: from the moment of execution until FMSA receives written confirmation from the National Gambling Board ("NGB") that my self-exclusion has been registered on the national register of excluded persons under Section 14 of the National Gambling Act 7 of 2004 ("NGA"). After that confirmation, the operative mandate terminates automatically, though FMSA may continue to assist with enforcement follow-up under the residual authority in Part C.4;
- **Accepted:** FMSA accepts this mandate and undertakes to act in good faith, within the scope of the authority granted, in accordance with my best interests, and without conflict of interest throughout the submission and follow-up process.

### B.2 ECTA Section 25 Attribution

Under ECTA Section 25, a data message is attributed to the originator where it was sent by a person authorised by the originator to do so. By executing this certificate, I confirm that:
1. FMSA is authorised to transmit my NGB Form 1/1 and all associated documents to the NGB and all nine Provincial Gambling Boards as my agent;
2. All such data messages, electronic communications, and submitted forms are attributed to me as the originator;
3. The transmission is legally mine even though FMSA physically transmits it.

---

## Part C: Scope of Mandate and Authority

### C.1 Submission to the National Gambling Board

FMSA is authorised to:

1. Complete, finalise, and submit NGB Form 1/1 (prescribed by Government Gazette No. 26994, 12 November 2004) to the National Gambling Board on my behalf;
2. Attach all supporting documentation required by the NGB Form 1/1 or any additional requirement of the NGB, including this Proxy Consent and Authorisation Certificate and the FMSA Self-Exclusion Submission Certificate;
3. Sign and execute any accompanying covering letter, proxy declaration, or transmission record required by the NGB or any Provincial Gambling Board in connection with my application;
4. Receive and act upon any correspondence, acknowledgement, request for further information, or notice from the NGB or any Provincial Gambling Board in connection with my application;
5. Follow up with the NGB if acknowledgement of receipt is not received within 24 hours of submission, and escalate to the NGB compliance office if no response is received within 72 hours.

### C.2 Submission to All Nine Provincial Gambling Boards

FMSA is authorised to simultaneously transmit my NGB Form 1/1 and this certificate to all nine Provincial Gambling Boards, being:

| Board | Province |
|---|---|
| Gauteng Gambling Board (GGB) | Gauteng |
| Western Cape Gambling and Racing Board (WCGRB) | Western Cape |
| KwaZulu-Natal Economic Regulator Authority (KZNERA) | KwaZulu-Natal |
| Eastern Cape Gambling Board (ECGB) | Eastern Cape |
| Limpopo Gambling Board (LGB) | Limpopo |
| Mpumalanga Economic Regulator (MER) | Mpumalanga |
| North West Gambling Board (NWGB) | North West |
| Free State Gambling, Liquor and Tourism Authority (FSGLTA) | Free State |
| Northern Cape Gambling Board (NCGB) | Northern Cape |

This simultaneous transmission to the NGB and all nine PGBs supports and supplements the NGB's obligation under Regulation 2(4) of the National Gambling Regulations 2004 to transmit notice to all licence holders and provincial licensing authorities within seven days of receipt.

### C.3 Authority as to All Licensed Gambling Operators

I acknowledge and understand that:

1. Under Regulation 2(4) of the National Gambling Regulations 2004 (GG No. 26994, 12 November 2004), the NGB is obliged to transmit a copy of my self-exclusion notice to **all licence holders** and provincial licensing authorities within seven days of receiving it;

2. "All licence holders" includes every entity holding a licence issued by the NGB or any Provincial Gambling Board under the NGA, including:
   - All land-based casino licence holders operating under applicable provincial gambling legislation;
   - All online gambling licence holders (including sports betting, casino games, bingo, lotteries, and all forms of licensed remote or internet gambling);
   - All gambling machine route operators, limited payout machine operators, and all other licensed operators in all nine provinces;

3. I hereby grant FMSA authority to communicate with any such licensed operator, whether land-based or online, directly or through the NGB and Provincial Gambling Boards, for the purpose of:
   - Facilitating enforcement of my self-exclusion where an operator has been notified by the NGB or a PGB;
   - Following up on compliance where FMSA has reason to believe that a licensed operator has not implemented my exclusion;
   - Reporting a suspected breach of self-exclusion by a licensed operator to the relevant Provincial Gambling Board or the NGB;
   - Requesting confirmation from a licensed operator, where legally permissible, that my exclusion has been recorded in its systems;
   - Taking any other reasonable step in furtherance of the enforcement of my statutory self-exclusion;

4. FMSA's authority to communicate with licensed operators is limited to the purposes set out in this Part C.3 and does not extend to commercial or contractual dealings with any operator on my behalf.

### C.4 Follow-Up, Escalation, and Monitoring

FMSA is authorised to:

1. Monitor for acknowledgement of receipt of my submission from the NGB;
2. Send follow-up correspondence to the NGB if acknowledgement is not received within 24 hours of submission;
3. Escalate my application to the NGB compliance office if no acknowledgement is received within 72 hours;
4. Escalate further to the Department of Trade, Industry and Competition (DTIC) if the NGB fails to respond within a further reasonable period;
5. Notify me by email when written confirmation of registration is received from the NGB in terms of Regulation 2(5)-(6) of the National Gambling Regulations 2004;
6. Maintain a case management record of all correspondence in connection with my application for the retention period specified in the FMSA Privacy Policy;
7. Report any suspected breach of my self-exclusion by a licensed operator to the applicable Provincial Gambling Board or the NGB on my behalf;
8. Assist me in lodging a formal complaint with the relevant Provincial Gambling Board if a licensed operator permits me to gamble during my exclusion period.

### C.5 Excluded Authority

This mandate does not authorise FMSA to:

- Enter into any contract on my behalf;
- Accept or reject any offer on my behalf;
- Handle, receive, or transmit funds on my behalf;
- Waive, settle, or compromise any right or claim I may have against any person or entity, including any licensed gambling operator;
- Disclose my personal information to any party other than those expressly named in this certificate, the NGB Form 1/1, the FMSA Privacy Policy, the NGB Submission Notice, and the Commission and Referral Disclosure;
- Take any step not reasonably necessary for the submission, follow-up, and enforcement of my self-exclusion.

---

## Part D: Legal Basis and Statutory Framework

### D.1 Legislative Framework

This appointment is made within and supported by the following legislative framework:

| Instrument | Provision | How It Applies to This Certificate |
|---|---|---|
| NGA Section 14(1) | Self-exclusion by written application | FMSA's electronic submission of NGB Form 1/1 satisfies the "written application" requirement on behalf of the Applicant as authorised representative |
| NGA Section 14(4) | Licensed operators must enforce self-exclusion | Operator enforcement obligation arises on notification; FMSA's authority to follow up on compliance is anchored here |
| National Gambling Regulations 2004, Regulation 2(4) | NGB must transmit to all licence holders within 7 days of receipt | Establishes the pipeline through which ALL licensed operators (land-based and online) are notified; FMSA's mandate to follow up on this transmission rests here |
| National Gambling Regulations 2004, Regulation 2(5)-(6) | Written confirmation triggers effectiveness of exclusion | Legal effectiveness of exclusion follows NGB confirmation; FMSA tracks and notifies the Applicant on receipt |
| ECTA Section 25 | Attribution of data messages to the originator through an authorised representative | The NGB Form 1/1, this certificate, and all electronic communications submitted by FMSA are attributed to the Applicant as originator through their appointed representative |
| ECTA Section 13(2) | Electronic signature not without legal force merely because in electronic form | The Applicant's single electronic signature has legal force under ECTA and simultaneously executes all three documents in this bundle |
| ECTA Section 14 | Parties may agree on electronic signing | The Applicant's consent to sign electronically (confirmed in Step 3 of the SE flow) satisfies Section 14 |
| ECTA Section 15 | Electronic evidence is admissible | All documents in this bundle are admissible as evidence in South African legal proceedings |
| POPIA Section 11(1)(b) | Processing with express written consent of the data subject | The Applicant's express written consent in this certificate authorises FMSA to process and share their personal information for the purposes set out in Part E |
| POPIA Section 26 | Special personal information (biometrics, race) | Where biometric data or race information has been provided, processing is subject to explicit separate consent under POPIA Section 26 as disclosed in the Biometric and Special Data Notice |
| PAIA Section 51 | PAIA manual for private bodies | FMSA's PAIA Manual details records held and procedures for access requests |

### D.2 Common-Law Mandate

This appointment also constitutes a mandate under common law, governed by the South African law of agency, by which the Applicant authorises FMSA to act on their behalf within the scope described in Part C. A common-law mandate:
- Requires the agent to act within the authority granted and not to exceed it;
- Requires the agent to act with good faith, diligence, and skill;
- Requires the agent to account to the principal for all actions taken under the mandate;
- Creates personal liability in the agent for wilful misconduct or gross negligence.

FMSA accepts all obligations flowing from common-law agency and undertakes to comply with them throughout the mandate.

### D.3 Signature Standard

The electronic signature applied in Step 3 of the SE flow is applied under ECTA Section 13(2). The applicable signature standard for NGB Form 1/1 is subject to any statutory, regulatory, or procedural requirement imposed by the NGB. FMSA will comply with any such requirement and will notify the Applicant if a different signature format is required.

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## Part E: POPIA Consent for Data Sharing with Operators and Regulatory Bodies

### E.1 Consent Statement

In granting the authority in Part C.3, I explicitly consent, for the purposes of POPIA Section 11(1)(b), to:

1. **Disclosure to the NGB:** FMSA sharing my NGB Form 1/1 and all accompanying documents with the National Gambling Board for the purpose of processing my self-exclusion application and registering me on the national register of excluded persons;

2. **Disclosure to all nine PGBs:** FMSA transmitting copies of my NGB Form 1/1 and this certificate to all nine Provincial Gambling Boards simultaneously with the NGB submission, for the purpose of ensuring that all provincial licensing authorities are notified of my exclusion;

3. **Disclosure to licensed gambling operators (via the NGB):** The NGB and Provincial Gambling Boards sharing my exclusion details with all licensed gambling operators in South Africa under Regulation 2(4) of the National Gambling Regulations 2004. I understand that this means my name, South African Identity Number, physical descriptors (height, build, eye colour, hair colour, distinguishing features, and photograph), exclusion scope, and exclusion duration will be transmitted to all licensed gambling operators, both land-based and online, in South Africa;

4. **Direct communication by FMSA with licensed operators:** FMSA sharing my exclusion record and a reference to this certificate directly with individual licensed gambling operators for the limited purposes described in Part C.3, specifically enforcement follow-up and breach reporting;

5. **Retention by operators:** Licensed gambling operators receiving my personal information retaining and processing it for the sole purpose of identifying me on their premises or platforms and enforcing my exclusion as required under Section 14(4) of the NGA and applicable licence conditions.

### E.2 Scope and Limitations of Consent

I understand that:
- This consent relates only to the disclosures described in Part E.1 and does not authorise any secondary use, commercial use, or profiling of my information by operators or any other party;
- Licensed gambling operators are prohibited from using my personal information for marketing purposes;
- My physical descriptors and photograph are shared for the sole purpose of enabling venue security and online verification systems to identify and enforce my exclusion;
- I may report any misuse of my personal information to FMSA at exclusions@freemesouthafrica.co.za, or directly to the Information Regulator at https://inforegulator.org.za;
- My right to withdraw consent for optional processing (such as IGHAC race data reporting) is set out in the FMSA Privacy Policy. Withdrawal of consent for the disclosures in Part E.1 is not possible without withdrawing the SE application, as those disclosures are required by law.

### E.3 Statutory Disclosure vs Consent-Based Disclosure

I acknowledge the distinction between:
- **Statutory disclosures** (NGB Form 1/1 to NGB and PGBs, and onward transmission to operators via Regulation 2(4)): these are required by law and do not depend on this consent, though I have consented to them in any event; and
- **Consent-based disclosures** (FMSA's direct follow-up communications with individual operators under Part C.3): these depend on the consent in Part E.1 and are within FMSA's discretion to use when appropriate for enforcement purposes.

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## Part F: Mirror Signature Doctrine

A single electronic signature applied in Step 3 of the FMSA Self-Exclusion Platform simultaneously executes this certificate, the NGB Form 1/1, and the FMSA Self-Exclusion Submission Certificate as a cryptographically linked document set.

The Mirror Signature Doctrine means:
- One informed act of consent executes all three statutory instruments simultaneously;
- All three documents carry the same SHA-256 Signature Hash and the same UTC timestamp;
- The hash links are tamper-evident: alteration of any document after signing changes its hash and makes the tampering detectable;
- The signature appears in the footer of every page of the NGB Form 1/1, in the execution clause of this certificate, and on the FMSA Self-Exclusion Submission Certificate.

By applying that single e-signature, the Applicant:

1. Confirms they have read and understood the full contents of this certificate, the NGB Form 1/1, and the FMSA Self-Exclusion Submission Certificate;
2. Voluntarily and of their own free will appoints FMSA as their authorised representative for all purposes described in Part C;
3. Confirms that the appointment is made without coercion, undue influence, duress, or misrepresentation;
4. Confirms that they are applying for self-exclusion for their own benefit and not at the direction of any third party who would benefit commercially from their exclusion;
5. Consents to the data processing and sharing described in Part E;
6. Acknowledges that this certificate forms part of the statutory document bundle submitted to the NGB and that it will be retained by FMSA for the period specified in the FMSA Privacy Policy;
7. Acknowledges that the self-exclusion, once registered by the NGB, cannot be shortened for the duration selected and that a lifelong exclusion is permanent under current NGA provisions.

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## Part G: Counselling Support and Voluntary Nature of Exclusion

### G.1 Voluntary Nature

Self-exclusion is entirely voluntary. The NGA does not require you to have a gambling disorder, to be experiencing gambling harm, or to meet any clinical threshold before applying. You may self-exclude for any personal reason, including financial protection, preventative action, or personal wellness.

FMSA does not require you to label yourself as a "problem gambler" or to accept any clinical diagnosis as a condition of this appointment. NGB Form 1/1 Declaration 2 has been reworded by FMSA to reflect the voluntary nature of the choice without imposing a clinical classification. The regulatory intent of NGA Section 14 is fully preserved.

### G.2 Support Resources

Whatever your reason for applying, FMSA recognises the value of connection to support:

- **National Responsible Gambling Programme (NRGP):** 0800 006 008 (toll-free, 24 hours, 7 days a week)
- **NRGP WhatsApp:** 076 675 0710
- **Gamblers Anonymous South Africa:** www.gamblerssouthafrica.org
- **BetBlocker (free device-blocking):** betblocker.org
- **SADAG Crisis Line:** 0800 567 567 (toll-free, 24 hours)

FMSA can arrange a free confidential counselling referral through the NRGP or South African Responsible Gambling Foundation (SARGF) at any time. You may request a referral during Step 1 of the registration flow or at any time via your dashboard. Requesting a referral is entirely voluntary and has no effect on this appointment or your SE application.

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## Part H: Termination of Mandate

### H.1 Automatic Termination

The operative mandate (Part C.1 and C.2) terminates automatically upon the earliest of:

1. Written confirmation from the NGB that the Applicant's exclusion has been registered on the national register of excluded persons under Regulation 2(5)-(6);
2. Expiry of the self-exclusion period as confirmed by the NGB.

### H.2 Residual Authority

Following automatic termination, FMSA retains the authority in Part C.3 and C.4 (enforcement follow-up, breach reporting, and monitoring) for the duration of the Applicant's active self-exclusion period.

### H.3 Withdrawal Before Confirmation

The Applicant may withdraw this mandate in writing to exclusions@freemesouthafrica.co.za at any time before FMSA has submitted NGB Form 1/1 to the NGB. Once submitted, the mandate for the submission itself cannot be undone as the NGB Form 1/1 will have been received by the NGB. However, the Applicant may contact the NGB directly to request amendment or cancellation of their application at that stage.

### H.4 Continuity of SE Registration

Termination of this mandate does not terminate the Applicant's statutory self-exclusion, which continues in full force and effect with the NGB for the duration selected.

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## Part I: Execution Record

This certificate is electronically executed by the Applicant. The execution record is maintained in the FMSA secure database and is associated with the following identifiers:

| Field | Value |
|---|---|
| SE Reference Number | [Generated at registration] |
| Execution Timestamp (UTC) | [Recorded at time of e-signature] |
| Signature Mode | [Type or Draw (as selected)] |
| SHA-256 Signature Hash | [Hash of entire document set; first 16 characters displayed on each page of PDF] |
| FMSA IP Record | [Encrypted; retained per FMSA Privacy Policy] |
| FMSA Witness | Administered electronically through the FMSA Self-Exclusion Platform |
| NGB Submission Timestamp | [Recorded on submission to the NGB] |

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*Free Me South Africa (Pty) Ltd | Reg. 2025/384802/07 | exclusions@freemesouthafrica.co.za*

*National Gambling Act 7 of 2004 | National Gambling Regulations 2004 (GG No. 26994) | Electronic Communications and Transactions Act 25 of 2002 | Protection of Personal Information Act 4 of 2013 | Promotion of Access to Information Act 2 of 2000*

*This document is a statutory instrument forming part of the NGB Form 1/1 submission bundle. Version 3.0 | 24 August 2026*