Form A. Client Registration & Agent Registration – NICTA TA

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NICTA Type Approval

Form A. Client Registration & Subscription Form (TT100 Part A)

~Please Read~

Please review the application form details before populating. Mismatches and discrepancies will ultimately result in the denial of application for type approval. Do ensure to copy the Submission ID for reference prior to commencement of application process.

Form A: Client & Agent Registration

User/Membership Registration

Step 1 of 2

50%

Submission ID

Type Approval | SM -

Submission Type

New Client Registration

Existing Client

Username

Password

Client Details

Type of Client

Client Full Name

Title First Name Middle Name Last Name

Occupation and Position

Phone/Telephone Number(s)

Client/User Phone Number

Email

Entity Details

Entity Location Category

Select the category of your entity whether it is based locally (registered business, agents, clients and individuals in PNG) or overseas (entity based in other countries or has overseas address).

Type of Entity

Homologation Business/Manufacturer Agent

Manufacturer

Overseas Distributor/Supplier

Test House/Lab

Overseas Registered Business

Local Agent

Local Business (Without NICTA License)

Local Organization (Non-profit)

Government Agency

Individual

NICTA Licensee

Entity Name

Type of License

For NICTA existing Licensee, please select the type of your license from the drop down menu

License Number

For NICTA Licensee, write the license number as it appears on your license

License Expiry Date

DD slash MM slash YYYY

IPA Certificate Number

IRC TIN

Website

Please provide the website of your entity

Entity Address / Location

Building & Street Address Post Office Box City State / Province / Region ZIP / Postal Code Country

Others

Summary or Brief Description of Representative and Entity

Please provide brief description of your entity

Purpose of Registration

Briefly explain why register or subscribe as a NICTA Client?

Attachments

Entity Documents

Max. file size: 25 MB.

Attach your Business Document here (Registration, Business Certificate, etc.).

ID Documents

Max. file size: 25 MB.

Entity Representative to attach NID, Driver License, Passport or work ID here.

Other Supporting Documents

Max. file size: 25 MB.

Any other supporting documents belong to the entity

Payment Details

Registration Fee

Price:

Registration Fee

Credit Card

Declaration

I agree to the privacy policy, terms and conditions and all the information submitted are true and correct!

By ticking the above, you hereby declare that all the information and particulars provided by you in this form and in the documents
submitted are to the best of your knowledge true, correct and complete. You understand that any untrue,
incorrect and/or incomplete information in this form and the documents submitted may lead to rejection of the
submission!

Account Information

Email

Username

Password

Enter Password Confirm Password

Date of Birth

MM slash DD slash YYYY

Option

Untitled

First Choice

Second Choice

Third Choice

Name

This field is for validation purposes and should be left unchanged.

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