Duvha-Janus

Response sheet / Antwoordvorm

This response sheet has been designed to assist you with your comments. The information provided will be used to guide the environmental studies and will contribute to ensuring that an informed decision is taken about the proposed activity.

Please return this questionnaire as soon as possible.

Click on "Submit" when you have completed it.

1. PERSONAL INFORMATION

   Title / titel: Dr Mr Mrs Miss

   First name and initials / naam en voorletters:

   Surname / van:

   Organisation representing / organisasie verteenwoordig: (e.g. Farmers Union, Provincial government)
   
   

2. PHYSICAL ADDRESS DETAILS / FISIESE ADRESBESONDERHEDE:

   Farm name / plaasnaam (as indicated on topographical map):

   Plot number of farm / gedeelte nommer van plaas:

   Plot name / plotnaam:

   Ownership / eienaarskap:
   Owner/eienaar Tenant/huurder

   Nearest town / naaste dorp:

3. CONTACT DETAILS / KONTAKBESONDERHEDE:

   Postal address / posadres:
   
   

   (postal code / poskode)
   

   Telephone number / telefoonnommer:

   Fax number / faksnommer:

   Cell number / Selnommer:

   E-mail / e-pos :

4. INVOLVEMENT / DEELNAME:

   Contact method preferred / metode van kontak verkies:

   Post	Fax	Home phone	Cell phone	Email
   Pos	Faks	Huis telefoon	Selfoon	E-pos

   Please note your involvement in the process / Dui asseblief u betrokkenheid by die proses aan:

   Take note	no further involvement	attend public meeting	comments attached
   Neem kennis	geen verdere betrokkenheid	woon publieke vergadering by	heg kommentaar aan

   Should you be aware of anybody else that should be informed, kindly provide their details below. Indien u bewus is van enige ander persoon wat in kennis gestel behoort te word, verskaf asseblief hulle besonderhede hieronder.

   Kindly note your concerns, issues relating to this project below. Skryf asseblief u vrae, kommentaar en bekommernisse i.v.m. hierdie projek hieronder.

   YOUR CONTRIBUTION IS HIGHLY APPRECIATED