Approved form AF2002-248

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 BH3
(see s33)
Australian Capital Territory

Boarding House Activity Licence Renewal Form

(See attached Boarding House Activity Licence Renewal Form)

Licence No:		Fee:		File No:	«File_No»	Expiry Date:		
Please complete this form, sign it and return it with the prescribed fee.  GST is not applicable under section 81-5 of the A New Tax System (Goods and Services Tax) Act 1999 (C’th).
Section 1 - Licensee
1	Licensee		
Title		First Name		Surname			
ABN		Company		
Please Note: To change the licensee details you must either complete a transfer form or submit a new application
Section 2 - Business Details
2	Trading Name		
Name			
3	Premises Address		
Shop No		Property Name			
Street No		Street			
Suburb		Postcode			
Section 3 - Contact Details
4	Contacts		
Contact Person for Licensee			
Business - Manager			
5	Business Contact Details	
Phone		Mobile		Fax			
Email			
6	Business Contact Details  -  Same as Question 5 	
Phone		Mobile		Fax			
Email			
Section 4 - Postal Details
7	Business Postal Address  -  Same as Question 3 		

Suburb		State		Postcode			
8	Postal Address for Licensing Correspondence  -  Same as Question 3  or Question 7 		

Suburb		State		Postcode			
Section 5 – Boarding House Details
9	Have you changed 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  			
10	Have you changed the structure or accommodation layout of the business and not notified the Health Protection Service?  (If Yes, please contact the Health Protection Service)	Yes  No  	

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 6 - 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	$ 100		
I agree for the Health Protection Service to debit my above 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 licence.	
	By Mail: Health Protection Service, Locked Bag 5, Weston Creek  ACT  2611.		In Person: Health Protection Service, 25 Mulley Street, Holder ACT.	
	Online: www.canberraconnect.act.gov.au 			

OFFICE USE ONLY
File No: _________________			 Licence No _____________________

Form - BH3