Approved form AF2002-237

Approved by the General Manager of the Health Protection Service on 16.12.2002 under the

Public Health Act 1997, s137A

Public Health Act 1997—Form DW1
(see s29)
Australian Capital Territory

Drinking Water Utility Activity Licence Application Form

(See attached form entitled Drinking Water Utility Activity Licence Application Form)

Please complete this form, sign it and return it with the prescribed fee. 
Section 1 - Applicant's Details
1	Licensee (Person or company)		
Title		First Name		Surname		
ABN		Company		
Section 2 - Business Details
2	Trading Name		
Name		
3	Premises Address		
Property Name		Shop No		
Street No		Street		
Suburb		Postcode		
Section 3 - Contact Details
4	Contacts		
Contact Person for Licensee		
Business - Manager		
5	Business Contact Details		
Phone		Mobile		Fax		
E-mail		
6	Licensees' Contact Details  -  Same as Question 5 		
Phone		Mobile		Fax		
E-mail 		
Section 4 - Postal Details
7	Business Postal Address  -  Same as Question 3 		

Suburb		State		Postcode		
Section 5 - Fees
Application Fee $60,000.
•	GST is not applicable under section 81-5 of the A New Tax System (Goods and Services Tax) Act 1999 (C’th).  
PLEASE SEE SECTION 7 (PAGE 2) FOR PAYMENT OPTIONS
Section 6 - Declaration
I declare that all the information supplied on this form is true and correct and the necessary records and / or documentation exist to support this application.	
Signature of Licensee		Date				
Print Name		Position
Title				
OFFICE USE ONLY
Licence granted  Yes  No  	Conditions  Yes  No  	Officer's Signature______________________	Date_________

Section 7 - Payment
Payment Method - Please Tick ()	Cash 	Cheque 	Credit Card 	
Note: Cheques should be made payable to the Health Protection Service. 	
Contact Person			
				
Type of Credit Card - Please Tick ()	Visa 	Master Card 	Bankcard 	
Credit Card No	Expiry Date	
   	/	
Cardholders' Name			
		
Fee	$ 60,000		
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		
	By Mail: Health Protection Service, Locked Bag 5, Weston Creek  ACT  2611.		In Person: Health Protection Service, 25 Mulley Street, Holder ACT.	
	Fax: 6205 1705 			
Note: For fax payments you are still required to sign and return this form prior to the issue of your licence.	

OFFICE USE ONLY
File No: _________________			 Licence No _____________________