CNA

APPLICATION FOR LICENSEE TO CHANGE NAME, ADDRESS
OR PHONE CONTACT

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.ors.act.gov.au.  This form may be used for the purpose of the Licensee changing the name, address or telephone contact number in accordance with section 42 of the Act.

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

LICENCE ATTACHED		LICENCE NUMBER	
		     	

DETAILS PRIOR TO CHANGE - FULL NAME OF LICENSEE 	
     	
LICENSEE ADDRESS (Property Name, Unit, Flat, Room No, Street Number, Street Name, City/Suburb/Town, Postcode)	
     	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

DETAILS TO BE RECORDED ON THE REGISTER AFTER THE CHANGE – FULL NAME OF LICENSEE	
     	
LICENSEE ADDRESS (Property Name, Unit, Flat, Room No, Street Number, Street Name, City/Suburb/Town, Postcode)	
     	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

STATUTORY DECLARATION BY LICENSEE IF THE LICENCE IS NOT ATTACHED TO THE APPLICATION	

I …………………………………………………………………………….of……………………………………………………………………….
(Name)                                                                                         (Address)
………………………………………………………………………………………………………………………..
(Occupation)

hereby declare that the Charitable Collection Licence No                                  issued to ……………………………………………………has been lost, mislaid or destroyed.

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statement in this declaration is true in every particular.

Declared at ………………………………………………on the ……………………day of ……………………………………….20

Signature of person making the declaration ………………………………………………………………………………………….

Signature of person before whom the declaration is made  ……………………………………………………………………….

Address of person before whom the declaration is made …………………………………………………………………………Qualification* ………………………………………….

Full name, qualification* and address of person before whom the declaration is made (in printed letters) (* Must be authorised under Statutory Declarations Act 1959)