Approved form AF2002-247

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 BH4
(see s34)
Australian Capital Territory

Boarding House Activity Licence Variation Form

(See attached Boarding House 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	Boarding House Details	  Section 7
Section 3	Licensee

You cannot vary the Licensee using this form.  Please either complete a Transfer Form or submit a New Application.  These forms are 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		Postcode			
Section 5	Contact Details
3	Contacts		
Contact Person for Licensee			
Business - Manager			
4	Business Contact Details	
Phone		Mobile		Fax			
Email			
5	Business 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			
7	Postal Address for Licensing Correspondence  -  Same as Question 2  or Question 6 		

Suburb		State		Postcode			

Section 7	Boarding House Details
8	Are you changing the accommodation type?  (If Yes, please tick all appropriate boxes below)	Yes  No  	
	Bed and Breakfast 	Boarding House 	Caravan Park 	Guest House 
	Hostel  	Hotel   	Motel 	Student Accommodation 
Other  			
9	Are you changed the structure or accommodation layout of the premise and not notified the Health Protection Service?  (If Yes, please supply floor plans detailing the changes.)	Yes  No  	
Section 8	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
Variation approved  Yes  No  		Officer's Signature______________________	Date_________

Form – BH4