Lease/Site Details Please Print

If more than one lease/site, attach the following details for each lease/site

Block	
		Section			Suburb		
	
Street Address/s	

	

Lessees Declaration

This appointment relates to a development application to the Planning and Land Authority that relates to the abovementioned site/s.

I/we the lessee(s) (insert lessee/s names) ________________________________________________________ whose signature/s appears below appoint (insert name of person to be authorised as “the applicant")
_________________________________ whose signature appears below, to act on my/our behalf in relation to a  development application for the abovementioned site/s. This appointment is made under the Planning and Development Act 2007.

This authorises the applicant to pay all application fees, bonds and securities, liaise with the Planning and Land Authority when required, alter, amend or provide further information as necessary and receive any communications relating to this Development Application.

This appointment is to remain valid until (enter date) ____________________ or until it is expressly withdrawn by written notice to both the applicant and also to the Planning and Land Authority; whichever occurs first.

I/We declare that:
•	I/we am/are the lessee(s) of the land described above;
•	I/we have been made aware of the declaration clauses in the Development Application form relevant to my application; and
•	I/we declare that all the information given on this form is true and complete.

1st Lessee’s Signature	
	Date		
				
2nd Lessee’s Signature	
	Date		

Applicant Declaration

I declare that I am the Applicant shown in the DA Form to be submitted to the Planning and Land Authority in relation to proposed development on the abovementioned site/s.

I declare that all the information given on this form and its attachments is true and complete;

Applicant Signature (s)	
	Date		

				
Privacy Notice
The personal information on this form is being collected to enable processing of your application. Collection of personal information is authorised by Chapters 7, 8 and 9 of the Planning and Development Act 2007. The information that you provide may be disclosed to the ACT Revenue Office and the Registrar-General’s Office. The information may be accessed by other government agencies, ActewAGL, ACTEW Corporation and other commercial organisations interested in development and building information. The Planning and Development Act 2007 requires the details of applications, decisions and orders to be kept on a register and made available for public inspection. Information and documentation relevant to a development application may be made available via the Internet.

Contact Details:
Environment and Sustainable Development Directorate
Customer Service Centre
GPO Box 1908, Canberra City 2601
16 Challis Street, Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)
Phone: (02) 6207 1923		Fax: (02) 6207 1925		TTY: (02) 6207 2622
Email: actpla.customer.services@act.gov.au	Website: www.actpla.act.gov.au