Approved form AF2002-251

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

Smoke-free Areas (Enclosed Public Places) Act 1994, s23

Smoke-free Areas (Enclosed Public Places) Act 1994—Form SF1
(see s 7)
Australian Capital Territory

Application for Smoke-free Exemption

(See attached Application for Smoke-free Exemption)

PART A	Applicant to complete
Section 1	Exemption Type (Please tick () one box only)
 Restaurant   Licensed Premises
Section 2	Occupier's Details
1	Occupier		
Title		First Name		Surname		
ABN		Company		
Note: Occupier means a person or corporation that is responsible for the management, control or is in charge of the business mentioned on this application.
Section 3	Business Details
2	Trading Name		
Name		
3	Premises Location		
Property Name		Shop No		
Street No		Street		
Suburb		Postcode		
Section 4	Contact Details
4	Contacts		
Contact Person for Occupier		
Business Manager		
5	Business Contact Details		
Phone		Mobile		Fax		
E-mail		
6	Occupier's Contact Details  -  Same as Question 5 		
Phone		Mobile		Fax		
E-mail 		
Section 5	Postal Details
7	Business Postal Address  -  Same as Question 3 		

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

Suburb		State		Postcode		
Section 6	Liquor Licence (Licensed Premises Exemption Applicants Only)
9	Does the premises hold a liquor licence?	Yes  No  	
Licence Type			
Section 7	Declaration
I declare that all the information supplied on PART A of this form is true and correct and the necessary records and / or documentation exist to support this application.	
Signature of Occupier		Date				
Print Name		Position
Title				

Section 8	Fees 
Please refer to the 'Application for Smoke-free Exemption - Information Sheet' for the appropriate fee
•	GST is not applicable under section 81-5 of the A New Tax System (Goods and Services Tax) Act 1999.
Section 9	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.	

OFFICE USE ONLY
File No: _________________			 Exemption No _____________________

PART B	MECHANICAL ENGINEER'S CERTIFICATION
Section 1	Exemption Type (Please tick () one box only)
 Restaurant   Licensed Premises
Section 2	Premises to Which Application Relates
1	Business Details		
Name		ABN		
Section 3	System Details
Nominated Area on Plan
(eg. "Area 1" or "bar")	System 
(eg. "A/C 1")	Area served (m2)	Maximum Occupancy	Outdoor air rate required per person (L/s)	Required Outdoor air supply (L/s)	Actual Outdoor air supply (L/s)	Exhaust fans (L/s)	Notes	
2	Non - Smoking Areas 		

									

									
									
Total								
3	Smoking Areas		

									

									
									
Total								
Provide an attachment for any additional systems
Total Areas		(Total public areas covered in this application)	

Section 4	Concessional Rates
4	If the mechanical ventilation system uses concessional rates, as permitted by AS 1668.2, please provide a complete description of equipment used:	

	

	
	
Section 5	Maintenance
5	Name of company or person performing maintenance	
Name		
ABN		Company		
6	Maintenance - Contact Details	
E-mail		
Phone		Fax		Mobile		
Section 6	Building Services Engineer’s Details
7	Engineer	
Name		
ABN		Company		
8	Engineer's Address	

Suburb		State		Postcode		
9	Engineer's Contact Details	
E-mail		
Phone		Fax		Mobile		
Section 7	Declaration
I declare that:
1.	the details provided on PART B of this application form are true and correct to the best of my knowledge; and
2.	the premises in this application is fitted with equipment capable of maintaining air quality in accordance with Australian Standard 1668.2.	
					
Signature of Building Services Engineer		NPER Registration/MIE (Aust) Number		Date	

OFFICE USE ONLY	
Exemption granted	Yes  No  	Officers Signature		Date