SCL

SURRENDER OF CHARITABLE COLLECTION LICENCE
BY LICENSEE

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 can be used for the purposes of a surrending a Charitable Collection Licence under Section 29 of the Act.

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

LICENCE ATTACHED			DATE OF SURRENDER		LICENCE NUMBER	
			     		     	

DETAILS OF LICENSEE / NOMINATED PERSON	

TITLE (eg. Ms, Mr, Dr)	FULL NAME OF LICENSEE / NOMINATED PERSON	
     	     	
APPLICANT ADDRESS (Property Name, Unit, Flat, Room No, Street Number, Street Name, City/Suburb/Town, Postcode)	
     	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

LICENSEE / NOMINATED PERSON SIGNATURE (if original licence is attached to the application)	
I confirm that the licence is to be surrendered:

Applicants Name in Full

Applicant Signature                                      Dated	Signed in my presence

Witnesses Name in Full

Witness Signature                                                   Dated

STATUTORY DECLARATION BY LICENSEE OR NOMINATED PERSON IF LICENCE NOT ATTACHED	

I …………………………………………………………………………….of……………………………………………………………………….

………………………………………………………………………………………………………………………..
(occupation)

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

And it make this solemn declaration by virtue of the Statutory Declarations Act 1959, and subject to the penalties provided by that Act for the making of false declarations, conscientiously believing the statements contain in this declaration to be true in every particular.

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

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

Full Name and 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)