This application is made under Section 256 of the Planning and Development Act 2007.

A valid application comprises of a completed application form accompanied by all of the required information or documents for it to be considered for approval.

Lease Details Please Print

Block	

Section	
	Unit (if applicable)		
		
Suburb	

District	

Street Number	

Street Name	

Postcode	

Applicant Details Please Print

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company/Business Number (ACN/ABN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	
	
Lessee (Property Owners) Details Please Print

1st Lessee’s Details 

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company/Business Number (ACN/ABN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

2nd Lessee’s Details 

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company/Business Number (ACN/ABN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

All lessees must sign authorising the lodgement of this application. In doing so the lessee gives authority to the applicant to negotiate any dealings in relation to the application through to its determination.  If there are more than two lessees please ensure that the details and authorisation are attached to the application.

Notice of Decision 

Unless otherwise specified your notice of decision will be returned via email

•	EMAIL		•	POST TO ME		•	HOLD FOR COLLECTION	

List of interested Parties

In accordance with section 257 of the Planning and Development Act 2007 written notice of this application must be provided to each person (other than the lessee) with a registered interest in the lease to which this application relates.  

Please list the names and addresses of all persons having a registered estate or interest (e.g. mortgagees, sub lessees) in the property:

Name	Address	Email Address	
1.			

2.	

	
3.	

	
4.	

	
5.	

	
6.	

	
7.			

8.			

PLEASE NOTE: If the list of interested parties changes during the time the assessment of the application is being undertaken it is the responsibility of the applicant to immediately notify the Planning and Land Authority.  Failure to do so could result in the decision being delayed or invalid.

Additional Information 

Information to be considered during the assessment of this application

Applicant and Lessee Declaration

I/we the undersigned, hereby apply for a decision on whether a the lease as specified in this application is a concessional lease;

I/we declare that this application is accompanied by all of the required information or documents for it to be considered for approval;

I /we understand that this application will be considered lodged once the relevant application fees have been paid;
I/we hereby authorise the Planning and Land Authority its servants and agents to erect sign/s on the subject property(s) as required;

I/we the undersigned (lessee) appoint the applicant whose signature appears below to act on my/our behalf in relation to this application. This authorises the applicant to pay all application fees, liaise with the Planning and Land Authority when required, alter, amend or provide further information as necessary and receive any communications relating to this application;

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

If signing on behalf of a company, organisation or Government agency: -

I/we the undersigned, declare I/we have the appropriate delegation or authority to sign on behalf of the company, organisation or Government agency.

Applicant Signature (s)	
	Date		
				
1st Lessee’s Signature	
	Date		
				
2nd Lessee’s Signature	
	Date		
				
All lessees must sign authorising the lodgement of this application. In doing so the lessee gives authority to the applicant to negotiate any dealings in relation to the application through to its determination.  If there are more than two lessees please ensure that the details and authorisation are attached to the application.

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. 

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