Approved form AF2002-239

Approved by the General Manager of the Health Protection Service on 6.12.2002 under the

Public Health Act 1997, s137A

Public Health Act 1997—Form DW3
(see s33)
Australian Capital Territory

Drinking Water Utility Activity Licence Renewal Form

(See attached Drinking Water Utility Activity Licence Renewal Form)

Licence No:		Fee:		File No:		Expiry Date:		
Please complete this form, sign it and return it with the prescribed fee.  GST is not applicable under section 81-5 of the A New Tax System (Goods and Services Tax) Act 1999 (C’th).
Section 1 - Licensee
1	Licensee		
Title		First Name		Surname			
ABN		Company		
Please Note: To change the licensee details you must either complete a transfer form or submit a new application
Section 3 - Business Details
2	Trading Name		
Name			
3	Premises Address		
Shop No		Property Name			
Street No		Street			
Suburb		State		Postcode			
Section 3- Contact Details
4	Contact Details for the Licensee (for administrative purposes)		
Contact Person for Licensee			
Business - Manager			
5	Business Contact Details	
Phone		Mobile		Fax			
Email			
6	Licensees’ Contact Details – Same as Question 5 	
Phone		Mobile		Fax			
Email			
Section 4 – Postal Details
7	Has your Business Postal Address changed? (If Yes, please indicate below)	Yes  No 	

Suburb		State		Postcode			
Section 5 - Declaration
I declare that all the information supplied on this form is true and correct and the necessary records and / or documentation exist to support this application.	
Signature of Licensee		Date				
Print Name		Position
Title				
OFFICE USE ONLY
Licence granted	Yes  No  	Conditions	Yes  No 	Officer's Signature		Date		

Section 6 - Payment
Payment Method - Please Tick ()	Cash 	Cheque 	Credit Card 	
Note: Cheques should be made payable to the Health Protection Service. 	
Type of Credit Card - Please Tick ()	Visa 	Master Card 	Bankcard 	
Credit Card No	Expiry Date	
   	/	
Cardholders' Name			
		
Fee	$ 60,000		
I agree for the Health Protection Service to debit my account for the above fee.	
Card Holder's Signature		Date			
Daytime Phone No					
How to Pay		
	Phone: 6205 1700 (Please have your credit card and this notice ready when you call). 		Fax: 6205 1705 	
Note: You are still required to sign and return this form prior to the issue of your licence.	
	By Mail: Health Protection Service, Locked Bag 5, Weston Creek  ACT  2611.		In Person: Health Protection Service, 25 Mulley Street, Holder ACT.	

OFFICE USE ONLY
File No: _________________			 Licence No _____________________