Charitable Collections
Licensee Report Form

This form must be completed in full by the licensee.

Licence No. ____________	Expiry Date ________

Individual  	Corporation 	Unincorporated body 

Section 1.
Licensee’s s details 

Mr 	Mrs  	Ms 	Miss 	Other _______________________

Surname ______________________________________________________

Given names ___________________________________________________

Corporation/Body__ _____________________________________________

Address _______________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Section 2
Please indicate how the collection was conducted and details of the period during which the collection was conducted.  (If more than one method was used to conduct the collection, please provide relevant information for each method of collection)

 Telephone

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

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

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

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

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

 Other (please specify) _________________________________________

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

Section 3
Record of Accounts –  Please provide account details for the collection conducted under licence.  If more than one collection has been conducted, please photocopy this page and provide details for each collection as an attachment.

Form of collection _______________________________________________

Details of Proceeds Received
Date	Proceeds received $ 	Date deposited 
into bank account*	

			

			

			

			
	$		
* Please attach bank deposit slips for amount/s deposited into bank account

Details of lawful/proper expenses* 
Date	Expense details**	Amount $	

			

			

			

			
		$	
•	Lawful/proper expenses include reasonable expenses incurred by the licensee in conducting and carrying out the collection, administering and distributing the proceeds of the collection complying with the Act and any other expenses stated in the application for the licence for the collection.

**	Where possible, please provide receipts for lawful/proper expenses incurred.

Net proceeds
(i.e. total proceeds received less total lawful/proper expenses)	$	

Section 4

Please provide any other information for each collection to which the licence relates as required by the conditions of the licence.

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

Section 5 
I, _______________________________________________________ 
	(Licensee’s full name)
declare that the information contained in this application is true and correct. 

Licensee Signature _____________________________________

Date ________________