ACL

APPLICATION FOR A NEW OR AMENDED
CHARITABLE COLLECTION LICENCE

IMPORTANT INFORMATION
Applicants should be aware of their responsibilities under the Charitable Collections Act 2003.  You can view the legislation and its regulations or download them from www.legislation.act.gov.au.  You may also obtain access to the Charitable Collections Practice Manual at and relevant forms at www.rgo.act.gov.au.  This form may be used for the purposes of applying for a licence (s21) or amending licence under section 34 of the Act. A licence is not required if proceeds received from collections is less than $15,000 in a financial year.	

Send completed applications to:  OFFICE OF REGULATORY SERVICES, PO BOX 225, CIVIC SQUARE, ACT 2608

This form may be used to apply for a new licence or to change the particulars of an existing licence. For a new licence, please tick the appropriate box and complete all sections below. If you are amending an existing licence, please tick the appropriate box and complete the items being amended (identified by a circle in the margin). 		New licence	
		amendment 	

TERM OF LICENCE 		COMMENCEMENT DATE		EXPIRY DATE		LICENCE NUMBER	
	 Office Use only	Office Use Only	Office Use Only
     		     		     		     	

TYPE OF LICENCE	

Amend Only

 Individual   	 Unincorporated  	 Corporation   	 Incorporated Body 	

CONTACT / NOMINATED PERSON DETAILS (Main contact with the Office of Regulatory Services)	

If the body is not incorporated, the applicant must be the nominated person in accordance with the Act.  The nominated person must also provide consent from the body to apply on their behalf (section 21(2)).  In the case of an unincorporated body, the nominated person will be the holder of the license. Please complete page one for each organisation applying for this licence.

Amend Only

TITLE
(eg. Ms, Mr, Dr)	FULL NAME OF APPLICANT / NOMINATED PERSON IF BODY NOT INCORPORATED	POSITION HELD WITHIN ORGANISATION 
(eg. Exec Officer)	
     	     	     	
APPLICANT ADDRESS (Property Name, Unit, Flat, Room No, Street Number, Street Name, City/Suburb/Town, Postcode)	
     	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

NAME OF ORGANISATION – REGISTERED NAME IF INCORPORATED (if incorporated, please provide a copy of the certificate of incorporation)	

Amend Only

AUSTRALIAN COMPANY NUMBER	AUSTRALIAN BUSINESS NUMBER	INCORPORATED ASSOCIATION (if applicable)	
			
REGISTERED OFFICE ADDRESS (Property Name, Unit, Flat, Room No, Street Number, Street Name, City/Suburb/Town, Postcode)	
	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

PURPOSE OF COLLECTION (refer to http://www.ato.gov.au/nonprofit/content.asp?doc=/content/24483.htm)	
The Chief Executive must be satisfied that the proposed purposes of the collection must be for a charitable purpose. The purpose of a collection must fall into one of the following categories.  
  the relief of poverty or sickness or the needs of the aged
 the advancement of education
  the advancement of religion
  the purposes beneficial to the community (philanthropic / patriotic / benevolent)
Provide more details supporting the base purpose of the collection: 

DOCUMENTATION IN SUPPORT OF PURPOSE	
In order for the Office of Regulatory Services to be in a position to appropriately assess the application and make a decision regarding the purpose of the collection it is very important that the applicant provide applicable governing documents.  Please select the documents that are being supplied in support of the application:
 certificate of incorporation
 consent from benefiting charity / charities (required only if application is not being made by the charity itself)
 trust deeds
 memorandums
 articles of association
 constitution / rules 
 business partnership agreement
 copies of previous annual returns over $50,000
 any other documents the applicant considers relevant to the application 

NAME OF AUDITOR (if collection expect to exceed $50,000)	
     	

Amend Only

AUDITORS ADDRESS	
     	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

NAME OF FINANCIAL INSTITUTION 	

Amend Only

     	
ACCOUNT NUMBER	NAME OF ACCOUNT	
     	     	

DECLARATION BY APPLICANT BEING AN INDIVIDUAL OR BEING THE NOMINATED PERSON SIGNING ON BEHALF OF A 
NON-INCORPORATED BODY	

I       
				                       (applicant)
declare that:
(i)	I have not, nor do I have an associate who has committed a disqualifying act; and
(ii)	I am not taking the benefit of any law for the relief of bankrupt or insolvent debtors; and
(iii)	I am not assigning any part of the income from this collection for the benefit of my own creditors.

I confirm that I understand that:

(i)	the authorisation of a licence will be subject to the requirements of the Charitable Collections Act 2003 and the Regulations of the Charitable Collections Act 2003, including any condition which may be imposed under them;

(ii)	I as the licensee, will be responsible for providing a report on collections conducted under the licence (regulation 14) in the format provided, and any other information that may be required under the licence conditions, within the timeframe stipulated under the licence conditions; and 

(iii)	an auditor’s report of accounts and records kept for collections conducted under the licence may be also required.

Applicants Name in Full

Applicant Signature                                      Dated	Signed in my presence

Witnesses Name in Full

Witness Signature                                                   Dated

DECLARATION BY COMPANY OR AN INCORPORATED ASSOCIATION (see note below)	

I       
			  (name of  company / incorporated body)
declare that:
(i)	I am not aware that an executive officer, or an associate of an executive officer, of the body has committed a disqualifying act; or
(ii)	the body is an externally–administered body corporate.

I confirm that I understand that:

(i)	the authorisation of a licence will be subject to the requirements of the Charitable Collections Act 2003 and the Regulations of the Charitable Collections Act 2003, including any condition which may be imposed under them;

(ii)	the licensee, will be responsible for providing a report on the collections conducted under the licence (regulation 14) in the format provided, and any other information that may be required under the licence conditions, within the timeframe stipulated under the licence conditions; and 

(iii)	an auditor’s report of accounts and records kept for collections conducted under the licence may be also required.

Full Name and position in company / incorporated body

Signature	

Full Name and position in company / incorporated body (or witness if signed by attorney

 Signature	
If the applicant has a Common Seal then it should be affixed in accordance with its rules or constitution.

____________________________
Common Seal (for incorporated body) 

NOTE: If the applicant is a corporation then the signatures on this application have to be (a) 2 directors; or (b) a director and a company secretary; or (c) the sole director (who is also the sole company director) and a witness; or (d) an attorney and a witness. If signed by this method, the attorney certifies that he/she has no notice of revocation of the power or attorney.  If the applicant is an incorporated association the two signatures on this application must be authorised officers.  If the applicant is an unincorporated association the signature must be from the nominated person or executive officer.	

DETAILS OF EACH COLLECTION FOR THE PURPOSES OF THE LICENCE	

PROVIDE DETAILS FOR EACH COLLECTION TO BE CONDUCTED UNDER THE CHARITABLE COLLECTIONS LICENCE (Section 9, Regulations) – identify times for children under 12	
As a licensee you are obligated to report to the Chief Executive under the following circumstances:
•	For a licence that is issued for a period of less than 12 months, you must report to the ORS within 120 days of the end of the licence.  
•	For a licence that is issued for a period of more than 12 months, you must report to the ORS within 120 days after the end of each 12 month period and within 120 days after the end of the licence.

As a licensee you are also obligated to provided audited reports of the above, if the income within any 12 month period exceeds $50,000.	
If an Amend, please tick	Type Of Collection	Name Of Charity / Charities Who Will Receive Proceeds	How the proceeds will be spent	Date Collection Starts	Date Collection Ends	Expected income from Collection 
$	Date Finalised Accounts Due To Office Of Regulatory Services (eg. 30 June and annually thereafter)	
	Personal (includes door to door and public place collections)	     	     	     	     	     	     	
	Telephone	     	     	     	     	     	     	
	Written appeals	     	     	     	     	     	     	
	Internet appeals	     	     	     	     	     	     	
	Other forms of electronic communication (Electronic Transactions Act 2001)	     	     	     	     	     	     	
	Collection bins  (includes clothing bins and any receptacle for receiving money or donations)	     	     	     	     	     	     	
	OTHER eg. Fetes, badge days, markets (please list)      	     	     	     	     	     	     	

COMMERCIAL FUNDRAISERS / RETAIL BUSINESSES (to be completed if a commercial fundraiser is being employed or retail business conducted)                                      ANNEXURE A	
COMMERCIAL FUNDRAISER		ADD TO EXISTING LICENCE		
RETAIL BUSINESS		REMOVE FROM EXISTING LICENCE		

NAME OF COMMERCIAL FUNDRAISER  / RETAIL BUSINESS  	NAME OF CONTACT PERSON	POSITION IN ORGANISATION	
     	     	     	
ADDRESS OF COMMERCIAL FUNDRAISER / RETAIL BUSINESS	
     	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

DETAILS OF PROPOSED COLLECTIONS (To be completed for new commercial fundraiser / retail business (Section 9, Regulations) – identify times for children under 12	
If an Amend, please tick	Type Of Collection	Date Collection Starts	Date Collection Finishes	Remuneration Payable to Commercial Fundraiser / Retail Business 	Expected income from Collection 
$	
	Personal	     	     	     	     	
	Telephone	     	     	     	     	
	Written appeals	     	     	     	     	
	Internet appeals	     	     	     	     	
	Other forms of electronic communication (electronic transactions act)	     	     	     	     	
	Collection bins	     	     	     	     	
	OTHER eg. Fetes, badge days, markets (please list)      	     	     	     	     	
	OTHER eg. Fetes, badge days, markets (please list)