Lease/Site Details Please Print

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

Block	
		Section			Suburb		
	
Street Address 	

Block	
		Section			Suburb		

Street Address 	

Lessee/Land Custodian Details  - if more than two lessees please provide details of each additional lessee  Please Print

1st Lessee Name/ 
Land Custodian	

2nd Lessee Name/ 
Land Custodian 	

AUTHORISATION

This appointment is made under the Planning and Development Act 2007 and relates to: (please tick)

•	Pre - application meeting for the abovementioned site/s. 
•	Development Application for the abovementioned site/s 
•	Reconsideration application for the abovementioned site/s.

I/we the lessee(s) authorise: 

___________________________________(Name) from _________________________________(company name) 

•	to obtain information in relation to this site through the pre-application process.

•	to act on my/our behalf in relation to a development application for the abovementioned site/s. 

•	to act on my/our behalf in relation to an application for a reconsideration of a development application for the abovementioned site/s. 

•	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 the Development Application or Application for Reconsideration.

LESSEE/LAND CUSTODIAN DECLARATION

•	I/we declare that I am/we are the lessee(s)/land custodian of the land described above;
•	I/we have been made aware of the declaration clauses in the Development Application or Application for Reconsideration form; and
•	declare that all the information given on this form is true and complete.

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

Land Custodian Signature	
	Date		

Authorised Person Declaration

I declare that I am the person authorised to sign/sign on behalf of the company described in this form

I declare that all the information given on this form and its attachments are true and complete;
			
Authorised Person Name	

Company Name (if relevant)	

Signature	
	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: esddcustomerservices@act.gov.au 	Website: www.environment.act.gov.au