Approved form AF2002-245

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 CT5
(see s56M)
Australian Capital Territory

Cooling Tower or Warm Water Registration Transfer Form

(See attached Cooling Tower or Warm Water Registration Transfer Form)

Section 1	Conditions of Transfer
•	This application must be signed by both the current registered person and the new applicant;
•	The original registration certificate must be submitted with this transfer application; and
•	This form must be completed and returned with the prescribed fee.
If these conditions cannot be met the new applicant must complete a new application form
Section 2	Current Registration Details

Regist No:			File No:			Expiry Date:		

Section 3	Fees
Transfer Fee $50 
•	Charities and Benevolent Institutions are fee exempt.  Please supply documentary evidence from the Australian Taxation Office.
•	GST is not applicable under section 81-5 of the A New Tax System (Goods and Services Tax) Act 1999 (C’th).
Section 4	Current Registered Person/Company Details 
1	Registered Person		
Title		First Name		Surname			
ABN		Company		
Section 5	Current Contact Details 
2	Contact Details for the Current Registered Person/Company		
Contact Person			
After Hrs		Phone		Mobile			
Fax		Email			
Section 6	Transfer Details
3	Current Registered Person to Complete:		
Please transfer this registration to the new entity below:	
Signature of Registered Person		Date			
Print Name					
4	New Registered Person to Complete: (Note: The New Registered Person is required to sign the Declaration at Section 13 - Page 3 of this form)	
(A)	New Registered Person		
Title		First Name		Surname			
ABN		Company		
Section 7	New Contact Details
5	Contact Details for the New Registered Person/Company		
Contact Person			
After Hrs		Phone		Mobile			
Fax		Email			

Section 8	New Postal Details
6	Postal Address for Registration Correspondence		

Suburb		State		Postcode			
Section 9	Changes to Registration Details
7	Have you made a significant modification to the system and not notified the Health Protection Service	Yes  No  	
If Yes, a practicing engineer's certificate certifying the cooling tower's or warm water storage systems compliance to the ACT Cooling Tower and Warm Water Storage System Code of Practice 2000 must accompany the renewal in light of the significant modification.	
8	Has there been a change of premises owner? (If Yes, Complete Section 10 - Page 2)	Yes  No  	
9	Has there been a change of premises manager? (if Yes, Complete 17 – Page 2)	Yes  No  	
10	Has there been a change of equipment owner? (if Yes, Complete 0 – Page 3)	Yes  No  	
11	Has there been a change of equipment manager? (if Yes, Complete Section 12 – Page 3)	Yes  No  	
If No to Questions 8, 9, 10 and 11, please go to Section 13 – Page 3		
Section 10	New Premises Owner
12	Person/Company who owns the premises where the cooling tower or warm water system is located	
Name			
13	Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
14	Physical Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
15	Postal Address 		

Suburb		State		Postcode			
16	Is the New Premises Owner a Commonwealth Government Agency?	Yes  No  	
17	New Premises Manager
18	Person/Company who managers the premises where the cooling tower or warm water system is located	
Company			
Name			
19	Premises Manager's Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
20	Premises Manager's Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
21	Premises Manager's Postal Address 		

Suburb		State		Postcode			

Section 11	New Equipment Owner
22	Person/Company who owns the cooling tower or warm water system	
Company			
Name			
23	Equipment Owner's Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
24	Equipment Owner's Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
25	Equipment Owner's Postal Address 		

Suburb		State		Postcode			
Section 12	New Equipment Manager
26	Person/Company who manages the cooling tower or warm water system	
Company			
Name			
27	Equipment Manager's Contact Details (for administrative purposes)		
Contact Person		E-Mail			
Phone		Fax		Mobile			
28	Equipment Manager's Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
29	Equipment Manager's Postal Address		

Suburb		State		Postcode			
Section 13	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 New Registered Person/Company		Date				
Print Name		Position
Title				

OFFICE USE ONLY	
Registration Transfer Approved	Yes  No  	Conditions	Yes  No 				
Officer's Signature		Date					

Section 14	Payment
Payment Method - Please Tick ()	Cash 	Cheque 	Credit Card 	
Note: Cheques should be made payable to the Health Protection Service. 	
Type of Credit Card - Please Tick ()	Visa 	Master Card 	Bankcard 	
Credit Card No	Expiry Date	
   	/	
Cardholders' Name			
		
Fee	$ 50		
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		
	Phone: 6205 1700 (Please have your credit card and this notice ready when you call). 		Fax: 6205 1705 	
Note: You are still required to sign and return this form prior to the issue of your registration certificate.	
	By Mail: Health Protection Service, Locked Bag 5, Weston Creek  ACT  2611.		In Person: Health Protection Service, 25 Mulley Street, Holder ACT.	

OFFICE USE ONLY
File No: _________________			Registration No _____________________