Approved form AF2002-240

Approved by the General Manager of the Health Protection Service on 6.12.2002 under the

Public Health Act 1997, s137A

Public Health Act 1997—Form DW4
(see s34)
Australian Capital Territory

Drinking Water Utility Activity Licence Variation Form

(See attached Drinking Water Utility Activity Licence Variation Form)

Licence No:			File No:			
Please complete this form, sign it and return it.  
Section 1	Conditions of Variation
•	This application must be signed by the current licensee; and
•	The original licence must be submitted with this variation application.
If these conditions cannot be met the new applicant must complete a new application form.
Section 2	Type of Variation
Licensee	  Section 3	Business Details	  Section 4	Contact Details	  Section 5
Postal Details	  Section 6
Section 3	Licensee

You cannot vary the Licensee using this form.  Please complete a new Application.  This form is available from the Health Protection Service.

Section 4	Business Details
1	Trading Name		
Name			
2	Premises Address		
Shop No		Property Name			
Street No		Street			
Suburb		State		Postcode			
Section 5	Contact Details
3	Contact Details for the Licensee (for administrative purposes)		
Contact Person for Licensee			
Business - Manager			
4	Business Contact Details	
Phone		Mobile		Fax			
Email			
5	Licensees’ Contact Details – Same as Question 4 	
Phone		Mobile		Fax			
Email			
Section 6	Postal Details
6	Business Postal Address  -  Same as Question 2 		

Suburb		State		Postcode			
Section 7	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					
OFFICE USE ONLY
Variation approved	Yes  No  			Officer's Signature		Date