Charitable Collections
Application for Licence (Individual)

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

Renewal of licence	 	Licence No. ____________	Expiry Date ________

Amend licence	 	Licence No. ____________	Expiry Date ________

Section 1
Applicant’s details i.e. person making the application and who will be responsible for the collection (applicant):

Mr 	Mrs  	Ms 	Miss 	Other _______________________

Surname ______________________________________________________

Given names ___________________________________________________

Address _______________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Section 2
Details of the purpose for which the licence is sought.  Please include the name of the charity to which benefits/proceeds will go to.
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Has the collection been approved by this charity?

Yes 		No 

Please attach written authorisation by the charity for the applicant to undertake this collection.

Section 3
Please indicate how the collection will be undertaken by the applicant and provide details of the time period during which the collection will be conducted.  (If the collection is to involve more than one form, please provide relevant information for each form)

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

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

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

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

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

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

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

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

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

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

 Other (please specify) _________________________________________

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

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

How will the collection be supervised? 

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________
(Please provide details in an attachment if more room is required)

How will the benefits/proceeds raised from the collection be distributed?
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________
(Please provide details in an attachment if more room is required)

Section 4
Will a commercial fundraiser be engaged for any aspect of the 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 5
Will any retail business be engaged for any aspect of the collection?

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 6 
Have you held a licence to carry out a collection for charitable purposes in the past?

Yes 		No 

If yes, please provide details of the nature 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?  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 7

•	I, ____________________________________________________
	(applicant’s full name)
declare that the information contained in this application is true and correct 

•	I understand 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.	as licensee, I will be responsible for providing a report on the collections conducted under the licence in the format provided at Appendix 1, 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.

Applicant’s signature ___________________________________________

Date	__________________________