RCL

APPLICATION FOR REPLACEMENT
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.ors.act.gov.au

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

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

TYPE OF LICENCE	
 Individual   	 Unincorporated  	 Corporation   	 Incorporated Body 	

APPLICANT 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.

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	
     	     	     	

STATUTORY DECLARATION	

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)