Approved form AF2002-241

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 CT1
(see s56F)
Australian Capital Territory

Cooling Tower and Warm Water Registration Application Form

(See attached Cooling Tower and Warm Water Registration Application Form)

Please complete this form, sign it and return it with the prescribed fee. 
Section 1 - Applicant's Details
1	Registered Person/Company		
Title		First Name		Surname			
ABN		Company		
Section 2 - Location of Registered System
2	Building Name where Registered System is Located		
Name			
3	Registered System's Address		
Street No		Street			
Suburb		Postcode			
4	Does a Commonwealth Agency own the Cooling Tower or Warm Water Storage System?	Yes  No 	
Section 3 - Contact Details
5	Contact Details for Registered Person/Company		
Contact Person			
After Hrs		Phone		Mobile			
Fax		E-Mail			
Section 4 - Postal Details
6	Postal Address for Registered Person/Company	

Suburb		State		Postcode			
Section 5 - Equipment Details
7	Cooling tower or warm water storage system details	
Name of Manufacturer		Model No			
Year of Manufacturer		Serial No			
Section 6 - Premises Owner
8	Person/Company who owns the premises where the cooling tower or warm water storage system is located	
Name			
9	Premises Owner's Contact Details		
After Hrs		Phone		Mobile			
Fax		E-Mail			
10	Premises Owner's Address		
Property Name		Shop No			
Street No		Street			
Suburb		State		Postcode			
11	Premises Owner's Postal Address  -  Same as Question 10 		

Suburb		State		Postcode			

Section 7 - Premises Manager
12	Are the Premises Manager's details the same as Section 6? (If Yes go to section 8)	Yes  No 	
A) 	Person/Company who managers the premises where the cooling tower or warm water storage system is located	
Title		First Name		Surname			
Company		ABN		
B) 	Premises Manager's Contact Details		
After Hrs		Phone		Mobile			
Fax		E-Mail			
C) 	Premises Manager's Address		
Property Name		Shop No			
Street No		Street			
Suburb		State		Postcode			
D) 	Premises Manager's Postal Address  -  Same as Question C 		

Suburb		State		Postcode			
Section 8 - Equipment Owner
13	Are the Equipment Owner's details the same as Section 6? (If Yes go to section 9)	Yes  No 	
A) 	Person/Company who owns the cooling tower or warm water storage system	
Title		First Name		Surname			
Company		ABN		
B) 	Equipment Owner's Contact Details		
After Hrs		Phone		Mobile			
Fax		E-Mail			
C) 	Equipment Owner's Address		
Property Name		Shop No			
Street No		Street			
Suburb		State		Postcode			
D) 	Equipment Owner's Postal Address  -  Same as Question C 		

Suburb		State		Postcode			
Section 9 - Equipment Manager
14	Are the Equipment Manager's details the same as Section 6? (If Yes go to section 10)	Yes  No 	
A) 	Person/Company who manages the cooling tower or warm water storage system	
Title		First Name		Surname			
Company		ABN		
B) 	Equipment Manager's Contact Details 		
After Hrs		Phone		Mobile			
Fax		E-Mail			
C) 	Equipment Manager's Address		
Property Name		Shop No			
Street No		Street			
Suburb		State		Postcode			
D) 	Equipment Manager's Postal Address Same as Question C 		

Suburb		State		Postcode			

Section 10 - Precise Location of System
15	Precise Location of System in Building	(eg Roof Top, Plant Room Level 3, etc)	

Section 11 - Fees
16	What is the registration period? (Please tick () one box only)	
Registration Period:	 1 Year   2 Years   3 Years   4 Years   5 Years	
Application Fee $200 per year.
•	Charities and Benevolent Institutions are fee exempt.  Please provide documentary evidence.
•	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 13 (PAGE 4) FOR PAYMENT OPTIONS
Note
1.	A practicing engineer’s statement certifying the system’s compliance to the ACT Cooling Tower and Warm Water Storage System Code of Practice 2000 must accompany the application;
2.	A practising engineer’s risk assessment must accompany the application;
3.	A cooling tower that comprises a water loop may be considered to be more than one cooling tower; and
4.	Charities and benevolent institutions are exempt from paying the registration renewal fee.  To qualify for exemption from the prescribed fee, proof of charity or benevolent institution status must be supplied.

Section 12 - 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 Registered Person/Company		Date			
Print Name		Position
Title			

OFFICE USE ONLY
Admin Officer: _______________________ 	Date forwarded to PHO ____________ 	PHO _________________________
High Risk Site 		Yes  No  	Fee 		Yes  No  	Engineer's Certification Yes  No 
Registration Approved 	Yes  No  	Conditions 	Yes  No 
Officer's Signature: _______________________ Date ____________

Section 13 - 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	$		
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 registration certificate.	

OFFICE USE ONLY
File No: _________________			 Registration No _____________________

Form - CT1