Australian
   Capital Territory
      Government

OFFICE USE ONLY

Application Number

___________________

Technical Check

___________________
Fees

___________________

Date Received

___________________

Receipt Number

___________________

Receiving Officer

___________________	
Land (Planning and Environment) Act 1991 – Form 6

Application for Reconsideration

Original Development Application (DA) number      __________________________________

Part 1: Lease/Site details:

If more than one lease/site, attach the following details for each lease/site.

                              Block:  ________________________
                             Section:  __________________________
             Unit (if applicable):  ________________
                              Suburb:  _________________________________________________________________
                              District:  _________________________________________________________________
                   Street Number:  ___________      Street Name:  ____________________________________
______________________________________________________________________

Part 2:     Applicant details:

                                        Surname:  _________________________________________________________
                                     First name:  _________________________________________________________
                              Company name:  _________________________________________________________
Australian Company Number (ACN):  _________________________________________________________
                If a company, position held
		within the company:  ________________________________________________________
                                 Postal Address:  ________________________________________________________
                                             Suburb:  ________________________________________________________
                                  State/Territory:  ___________________________ Postcode:  _________________
        Phone Number (business hours):  _______________________________________________________
                                      Fax Number:  _______________________________________________________
           Email:  _______________________________________________________________________________

All lessess must sign authorising the lodgement, and in doing so give authority to the applicant to negotiate any dealings with the application through to its determination by the relevant authority, or a Power of Attorney must be attached. If there are more than two lessees, please ensure that details and authorisation are attached to the application for each lessee.

If the lessee is a registered company, organisation or government agency you must execute this application in the proper manner for that company, organisation or government agency. For example, if the lessee is a community organisation, the full name of the community organisation must be stated and the signatory must  identify what position of authority he/she holds in the organisation.

To verify the signature of a lessee who is other than a registered company, i.e. a community, an organisation or government agency, a Letter of Authority must be supplied when lodging the application that empowers the signatory to sign on the behalf of that organisation or government agency.

Any application made over a site which has been Unit Titled will require Approval in accordance with the articles of association for that units plan.
	
Part 3:     Lessee (Property Owner) details
1st  Lessee’s details
                                 Surname name:  ______________________________________________________
                                       First name:  ______________________________________________________
                                Company name:  _____________________________________________________
    Australian Company Number (ACN): _____________________________________________________
               If a company, position held
	              within the company:  _____________________________________________________
                                   Postal Address:  ____________________________________________________
                                             Suburb:  ______________________________
                                  State/Territory:  ______________________________
                                          Postcode:  ______________________________
        Phone number (business hours):  __________________________________
                                      Fax number:  __________________________________
           Email:  _____________________________________________________________________________

*Lessee must sign Part 6 of the application form.

Part 3:     Lessee (Property Owner) details
2nd Lessee’s details
                                Surname name:  ______________________________________________________
                                       First name:  ______________________________________________________
                                Company name:  _____________________________________________________
    Australian Company Number (ACN): _____________________________________________________
                If a company, position held
	              within the company:  _____________________________________________________
                                 Postal Address:  ______________________________________________________
                                             Suburb:  ______________________________
                                  State/Territory:  ______________________________
                                          Postcode:  ______________________________
        Phone number (business hours):  __________________________________
                                      Fax number:  __________________________________
           Email:  _____________________________________________________________________________

*Lessee must sign Part 6 of the application form. 
Part 4:     Application for Reconsideration is being applied against

Please specify grounds on which reconsideration of the original decision is
sought.	
          Refusal of a Development Application
          Conditions of Approval (specify)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Part 5:     Amendment/s

Have you amended your plan/s to support your application for reconsideration?
		  No      Yes   (please attach a copy of the amended plans)
If yes, describe the impact (if any) on other conditions of approval.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Part 6:   Applicant’s & Lessee’s declaration
I/we the undersigned, hereby apply for approval to carry out the development described in this application in the land specified in this application:
I/we hereby direct and authorise the ACT Planning and Land Authority to erect sign/s on the subject property(s):
I/we hereby authorise ACT Planning and Land Authority Officers to access the subject property(s) for the purpose of evaluating the proposal.:
I/we understand that this application may be scanned and made available for public inspection via the internet: and
I/we declare that all the information given on this form and its attachments is true and complete.

CONFLICT OF INTEREST DECLARATION:    Does the applicant or lessee have any association with ACT Planning and Land Authority staff?
							   No      Yes

If yes, please provide details:  
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________

Applicant’s Signature(s)  __________________________________	Date  ______________________

1st Lessee’s Signature(s)  __________________________________	Date  ______________________

2nd Lessee’s Signature(s)  _________________________________	Date  ______________________

Privacy Notice:

The personal information on this form is being collected to enable processing of your application. Collection of personal information is authorised by Part VI of the Land (Planning and Environment) Act 1991. The information that you provide may be disclosed to the ACT Revenue Office and the Registrar-General’s Office. The information may be accessed by ACTEWAGL Corporation and commercial organisations interesting in building information.

The Land (Planning and Environment) Act 1991 requires the details of applications, approvals and orders to be kept on a register and made available for public inspection.

Inspection of development applications may be made available via the internet.	
Contact Details:

ACT Planning and Land Authority
Customer Service Centre
GPO Box 1908, Canberra City 2601
16 Challis Street, Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays
Phone: (02) 6207 1923
Fax:  (02) 6207 1925
TTY: (02)  6207 2622
Email: actpla.customer.services@act.gov.au
Website: www.actpla.act.gov.au