Charitable Collections
Application for Licence	

Send completed Applications to:
Charitable Collection Licences, PO Box 352, Civic Square, ACT 2608	

Applicants should be aware of their responsibilities under the Charitable Collections Act 2003. You can view the legislation and its regulations or download them from www.legislation.act.gov.au. You should also consult the Best Practice Guidelines (www.urbanservices.act.gov.au/charitable).	

An asterisk (*) indicates questions, which must be answered before an application can be processed.

* Is this licence for an: individual				unincorporated body	
incorporated body		corporation			

* Please indicate whether this application is for a new licence or if you are amending an existing licence:

New licence 	

Amend licence	 	Licence No. ____________	Expiry Date __________

* For what length of time is the licence required (maximum 5 years) ____________________________

Section 1
* Applicant’s details ie person making the application and who will be responsible for the collection and receive all correspondence and enquires about the licence:

Mr 	Mrs  	Ms 	Miss 	Other _________________________________________

Surname ________________________________________________________________________

Given names _____________________________________________________________________

Address _________________________________________________________________________

Telephone ___________________		Fax _____________________

Email ___________________________________________

* Organisation’s name and details (if applicable)

Name of applicant  _________________________________________________________________

Address _________________________________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

* In the case of an unincorporated body applying for the licence, is the executive officer completing this application the nominated person for the applicant body in relation to the licence?

Yes 		No 

* If no, please prove details of the “nominated person” and ensure that the nominated person completes and signs the declaration on page 7.

Mr 	Mrs  	Ms 	Miss 	Other _________________________________________

Surname ________________________________________________________________________

Given names _____________________________________________________________________

Address _________________________________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Section 2.
* In the case of a corporation, is the corporation externally administered? ie

(a)	is it being wound up?      			Yes       No 
(b)	has a receiver been appointed?     			Yes       No 
(c)	is it under administration?     			Yes       No 
(d)	is it subject to a deed of company agreement?     Yes       No  
(e)	has it entered into a compromise arrangement with another person, the administration of which has not been concluded?     				Yes       No 

Section 3.
*  Purpose of the collection.  Please state briefly who will benefit from the collection, what the proceeds of the collection will be used for, or how this will be achieved.  This statement justifies the collection is for a charitable purpose.  Example: ‘welfare services for needy Australians’.  Please include the name of the charity/charities to which benefits/proceeds will go.

_______________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Has the collection been approved by this charity or charities?

Yes 		No 

Please attach written authorisation by the charity or charities for the applicant to undertake this collection if the application is NOT being made by the charity itself.

Section 4.
* Please indicate how the applicant will undertake the collection and provide details of the time period during which the collection will be conducted.  (If the collection is of more than one type, please provide relevant information for each type)

 Personal (includes door to door and public place collections) 
From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

What time of day will the collection be undertaken?________________________________________

 Telephone
From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	mm	yr

What time of day will the collection be undertaken?________________________________________

 Written appeals  (includes written requests posted, addressed, sent or delivered to a person)
From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

 Internet
From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

 Other forms of electronic communication (see Electronic Transactions Act 2001)

(please specify) ___________________________________________________________________

From: _____/____/______ to ____/____/______ 
	dd	 mm	yr 	dd	 mm	yr

What time of day will the collection be undertaken?________________________________________

 Collection bins (including clothing bins and any receptacle for receiving money or donations)
From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

 Other (please specify) ____________________________________________________________
(eg. fetes, fairs, markets, open days, badge days etc.)
From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

What time of day will the collection be undertaken?________________________________________

 Other (please specify) ____________________________________________________________
(eg. fetes, fairs, markets, open days, badge days etc.)

From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

What time of day will the collection be undertaken?________________________________________

 Other (please specify) ____________________________________________________________
(eg. fetes, fairs, markets, open days, badge days etc.)

From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

What time of day will the collection be undertaken?________________________________________
Section 5.
*Will you employ a commercial fundraiser to be paid for any aspect of any collection?

Yes 		No 

If yes, please provide details:

Name of Organisation_______________________________________________________________

Contact Person ___________________________________________________________________

Position _________________________________________________________________________

Address _______________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Please provide details of the activity to be undertaken by the commercial fundraiser, including the time period that the activity will be carried out (if different to the information provided in Section 3). 

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Please provide details of remuneration payable to the commercial fundraiser or how the remuneration will be calculated.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

(If more than one commercial fundraiser is to be engaged please provide an attachment with relevant details for all other fundraisers)

Section 6.
*Will any retail business be conducted to generate collection proceeds?

Yes 		No 

If yes, please provide details:

Name of Business _________________________________________________________________

Contact Person ___________________________________________________________________

Position _________________________________________________________________________

Address _________________________________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Please provide details of the activity to be undertaken by the retail business, including the time period that the activity will be carried out (if different to the information provided in Section 3). 

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Please provide details of remuneration payable to the retail business or how the remuneration will be calculated.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

(If more than one retail business is to be engaged please provide an attachment with relevant details for all other businesses)

Section 7.
*Have you ever held a licence in the ACT to carry out a collection for charitable purposes?

Yes 		No 

If yes, please provide details of this activity and the period of time over which the activity was carried out.  

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

*Have you or an associate ever had a licence to carry out a collection for charitable purposes suspended or cancelled in the ACT or elsewhere?  NB.  A person is an associate in relation to an application for a licence if the person can, or will be able to, have significant influence over, or in relation to the carrying out of a collection to which this application relates.

Yes 		No 

If yes, please provide details. 

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

* Have you or an associate ever been convicted (in the ACT or elsewhere) of an offence involving fraud or dishonesty?  NB.  A person is an associate in relation to an application for a licence if the person can, or will be able to, have significant influence over, or in relation to the carrying out of a collection to which this application relates.

Yes 		No 

If yes, please provide details.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

* Are you taking the benefit of any law for the relief of bankruptcy or insolvent debtors or is any part of your income assigned for the benefit of creditors?

Yes 		No 

If yes, please provide details.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Section 8.

Please sign the relevant section.

I/The ___________________________________________________________________________
(applicant/corporation/incorporation/ unincorporated associations name)

declare that the information contained in this application is true and correct.

The applicant understands that:
i.	the authorisation of a licence will be subject to the requirements of the Charitable Collections Act 2003 and the Regulations of the Charitable Collections Act 2003, including any condition which may be imposed under them;
ii.	the licensee, will be responsible for providing a report on the collections conducted under the licence (regulation 14) in the format provided, and any other information that may be required under the licence conditions, within the timeframe stipulated under the licence conditions; and 
iii.	an auditor’s report of accounts and records kept for collections conducted under the licence may be also required.

_______________________________________		____________________________________
Signature of Applicant						Signature of Witness

_______________________________________		____________________________________
Print Name							Print Name

_______________________________________		____________________________________
Position Held or Address (if applicable)			Position Held or Address (if applicable)

_______________________________________		____________________________________
Date								Date	

If the applicant is an Incorporated Association:

If the applicant has a Common Seal then it should be affixed in accordance with its rules or constitution.

____________________________
Common Seal

NOTE: If the applicant is a corporation then the signatures on this application have to be (a) 2 directors; or (b) a director and a company secretary; or (c) the sole director (who is also the sole company director) and a witness; or (d) an attorney and a witness. If signed by this method, the attorney certifies that he/she has no notice of revocation of the power or attorney.

If the applicant is an incorporated association the two signatures on this application must be authorised officers.

If the applicant is an unincorporated association the signature must be from the nominated person or executive officer.