Approved form AF2002-253

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

Smoke-free Areas (Enclosed Public Places) Act 1994, s23

Smoke-free Areas (Enclosed Public Places) Act 1994—Form SF3
(see s9)
Australian Capital Territory

Smoke-free Annual Fee Reminder Notice

(See attached Smoke-free Annual Fee Reminder Notice)

Cert. No:		Fee:		File No:		Payment Due:		
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	Occupier's Details
1	Occupier		
Title		First Name		Surname			
ABN		Company			
2	Exemption Details	
Exemption Type		Total Floor Area		Expiry Date			
Please Note: The smoke-free Areas Act does not permit changes to the occupier's details. A new application must be submitted
Section 2	Business Details
3	Trading Name		
Trading Name			
4	Premises Location		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
Section 3	Contact Details
5	Contacts		
Contact Person for Occupier			
Business Manager			
6	Business Contact Details	
Phone		Mobile		Fax			
Name		E-mail			
7	Occupier’s Contact Details  -  Same as Question 6 	
Phone		Mobile		Fax			
Name		E-mail			
Section 4	Particulars of the Business
8	Business Postal Address  -  Same as Question 4 		

Suburb		State		Postcode			
9	Postal Address for Exemption Correspondence  -  Same as Question 4  or Question 8 		

Suburb		State		Postcode			
10	Do you wish to cancel the exemption? (If Yes, please contact the Health Protection Service)	Yes  No  	
11	Since your current exemption was issued has there been a change in the:		
	A) 	air-handling system? (If Yes please contact the Health Protection Service)	Yes  No  	
	B) 	designated smoking/non-smoking areas? (If Yes please contact the Health Protection Service)	Yes  No  	

Section 5	Declaration
I declare that all the information supplied on this form is true and correct and necessary records and / or documentation exist to support this application.	
Signature of Occupier		Date				
Print Name		Position
Title				

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	$		
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 continuation of your exemption.	
	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: _________________			 Certificate No _____________________