APPLICATION FOR A NEW OR AMENDED CHARITABLE COLLECTION LICENCE
Charitable Collections Act 2003
Charitable Collections Regulation 2003
		
PURPOSE 

This form is to be used when applying for a new licence or to change the particulars of an existing licence under the Charitable Collections Act 2003 (the Act).  You can access the legislation at www.legislation.act.gov.au.  You may also obtain further information and forms at www.ors.act.gov.au.
	
PRIVACY

The Act authorises the Director-General to collect the personal information required by this form for the purposes of issuing a licence under Division 4.1 of the Act.  Pursuant to Section 41 of the Act, the Director-General must keep a Register of Licenses that is available for inspection by the public. The Director-General prevents any unreasonable intrusion into a person’s privacy in accordance with the Privacy Act 1988 (C’wlth).  The Director-General may provide additional information to law enforcement agencies and authorised organisations that have legal authority to request information under prescribed circumstances.	
CONTACT
	
Office of Regulatory Services Shopfront
255 Canberra Avenue, Fyshwick ACT 2609	Office of Regulatory Services Postal Address
GPO Box 158, Canberra ACT 2601	
Opening Hours 9:00am to 4:30pm Monday to Friday	Website www.ors.act.gov.au      Email ors.bil@act.gov.au 	
General Enquiries (02) 6207 0562	Fax Number (02) 6207 0424	
INSTRUCTIONS FOR COMPLETION 

•	Complete this form using blue or black pen only.
•	Please print; ensuring writing is clear and legible. 
•	This office will not accept lodgement of this form if it is not completed in full.
	
IMPORTANT INFORMATION
•	Applicants should be aware of their responsibilities under the Charitable Collections Act 2003.  
•	This form may be used to apply for a new licence or to change the particulars of an existing licence. 
•	Where an individual or organisation collects less than $15,000 from ACT residents in a 12 month period a charitable collections licence is not required.  However, if you choose to hold a licence you must provide financial reports to the Director-General. 
•	The nominated person is the contact person between the licensee and the Office of Regulatory Services.
•	If a licence is issued to an unincorporated body, the nominated person for the body in relation to the licence is taken to be the licensee.
	
TRANSLATING AND INTERPRETING SERVICE
If you require further information or require advice, a language assistance service is available by phoning the Translating and Interpreting Service (TIS) on 13 14 50.	

APPLICATION FOR A NEW OR AMENDED CHARITABLE COLLECTION LICENCE– FORM ACL
Charitable Collections Act 2003
Charitable Collections Regulation 2003
	
NEW LICENCE		AMENDED LICENCE		

TERM OF LICENCE
(Up to five years)	COMMENCEMENT DATE (Office use only)	EXPIRY DATE              (Office use only)	LICENCE NUMBER     (Office use only)	

TYPE OF LICENCE	
  Individual                     Unincorporated                     Corporation              Incorporated body	

APPLICANT / CONTACT / NOMINATED PERSON DETAILS (Main contact with the Office of Regulatory Services)	
All applicants must complete this section. 
•	An individual applicant must provide his/her details. 
•	An incorporated organisation must provide the name and details of a contact person. 
•	Unincorporated organisations must nominate a person. The nominated person will be the holder of the licence. 
Please complete page one for each person/organisation applying for this licence

TITLE (eg. Ms, Mr, Dr)	FULL NAME OF APPLICANT / NOMINATED PERSON 	POSITION HELD WITHIN ORGANISATION (EG. Exec Officer)	
			
ADDRESS (Property name, unit, flat, room no, street number, street name, city/suburb/town, postcode)	
	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	

NAME OF ORGANISATION – REGISTERED NAME IF INCORPORATED (If incorporated, please provide a copy of the certificaet if incorporation)	
	
AUSTRALIAN COMPANY NUMBER	AUSTRALIAN BUSINESS NUMBER	INCORPORATED ASSOCIATION	
			
REGISTERED OFFICE ADDRESS (Property name, unit, flat, room no, street number, street name, city/suburb/town, postcode)	
	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	

PURPOSE OF COLLECTION (refer to http://www.ato.gov.au/nonprofit/content.aspx?doc=/content/24483.htm )	

The Chief Executive must be satisfied that the proposed purposes of the collection must be for a charitable purpose. The purpose of a collection must fall into one of the following categories.

  The relief of poverty or sickness or the needs of the aged

  The advancement of education

  The advancement of religion

  The purposes beneficial to the community (philanthropic / patriotic / benevolent)

Provide more details supporting the base purpose of the collection:	

DOCUMENTATION IN SUPPORT OF PURPOSE	

In order for the Office of Regulatory Services to be in a position to appropriately assess the application and make a decision regarding the purpose of the collection it is very important that the applicant provide applicable governing documents. Please select the documents that are being supplied in support of the application:

  Certificate of incorporation

  Consent from benefiting charity / charities (required only if application is not being made by the charity itself)

  Trust deeds

  Memorandums

  Articles of association

  Constitution / rules

  Business partnership agreement

  Copies of previous annual returns over $50,000

  Any other documents the applicant considers relevant to the application 	

NAME OF AUDITOR (If collection expected to exceed $50,000)	
	
AUDITOR’S ADDRESS	
	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	

NAME OF FINANCIAL INSTITUTION	
	
ACCOUNT NUMBER	NAME OF ACCOUNT	

DECLARATION BY APPLICANT BEING AN INDIVIDUAL OR BEING THE NOMINATED PERSON SIGNING ON BEHALF OF A NON-INCORPORATED BODY	

I ___________________________________________________________________________________________________________________________
                                                                                                                              (applicant)

declare that:

(i)	I have not, nor do I have an associate who has committed a disqualifying act; and

(ii)	I am not taking the benefit of any law for the relief of bankrupt or insolvent debtors; and

(iii)	I am not assigning any part of the income from this collection for the benefit of my own creditors.

I confirm that I understand that:

(i)	The authorisation of a licence will be subject to the requirements of the Charitable Collections Act 2003 and the Regulations of the Charitable Collections Act 2003, including any condition which may be imposed under them:

(ii)	I as the licensee, will be responsible for providing a report on collections conducted under the licence (regulation 14) in the format provided, and any other information that may be required under the licence conditions, within the timeframe stipulated under the licence conditions; and

(iii)	An auditor’s report of accounts and records kept for collections conducted under the licence may be also required.	

Applicant’s name in full

Applicant’s signature                                          Dated             /      /         	
Signed in my presence

Witness’ name in full

Witness signature                                                    Dated        /      /       	

DECLARATION BY A COMPANY OR AN INCORPORATED ASSOCIATION (see note below)	

I______________________________________________________________________________________________________________________________
                                                                                                         (name of company / incorporated body)

declare that:

(i)	I am not aware that an executive officer, or an associate of an executive officer, of the body has committed a disqualifying act; or

(ii)	The body is an externally-administered body corporate.

I confirm that I understand that:

(i)	The authorisation of a licence will be subject to the requirements of the Charitable Collections Act 2003 and the Regulations of Charitable Collections Act 2003, including any condition which may be imposed under them;

(ii)	The licensee will be responsible for providing a report on the collections conducted under the licence (regulation 14) in the format provided, and any other information that may be required under the licence conditions, within the timeframe stipulated under the licence conditions; and

(iii)	An auditor’s report of accounts kept for collections conducted under the licence may be also required.	

Full name and position in company / incorporated body

Signature                                                         Dated	

Full name and position in company / incorporated body (or witness if signed by an attorney)

Signature                                                           Dated	

If the applicant has a Common Seal then it should be affixed in accordance with its rules or constitution.

_____________________________
Common Seal (for incorporated body)

Note: If the applicant is a corporation then the signatures on this application have to be (a) 2 directors; or (b) a director and a company secretary; or (c) the sole director (who is also the sole company director) and a witness; or (d) an attorney and a witness.  If signed by this method, the attorney certifies that he/she has no notice of revocation of the power or attorney.  If the applicant is an incorporate association the two signatures on this application must be authorised officers.  If the applicant is an unincorporated association the signature must be from the nominated person or execitive officer.	

PROVIDE DETAILS FOR EACH COLLECTION TO BE CONDUCTED UNDER THE CHARITABLE COLLECTIONS LICENCE (Section 9, Regulations) – identify times for children under 12	

As a licencee you are obligated to report to the Director General under the following circumstances:
•	For a licence that is issued for a period of less than 12 months, you must report to the ORS with 120 days of the end of the licence.
•	For a licence that is issued for a period of more than 12 months, you must report to the ORS within 120 days after the end of each 12 month period and within 120 days after the end of the licence.

As a licensee you are also obligated to provide audited reports of the above, if the income within any 12 month period exceeds $50,000.	

Type of Collection	

Name of charity / charties who will receive proceeds	

How the proceeds will be spent	

Date collection starts	

Date collection ends	

Expected income from collection
$	

Date finalised accounts due to Office of Regulatory Services (eg. 30 June and annually thereafter)	

Personal (includes door to door and public place collections)	     	     	     	     	     	     	
Telephone	     	     	     	     	     	     	
Written appeals	     	     	     	     	     	     	
Internet appeals	     	     	     	     	     	     	
Other forms of electronic communication (Electronic Transactions Act 2001)	     	     	     	     	     	     	
Collection bins (includes clothing bins and any receptacle for receiving money or donations)	     	     	     	     	     	     	
Other (eg. Fetes, badge days, markets (please list))	     	     	     	     	     	     	
COMMERCIAL FUNDRAISERS / RETAIL BUSINESSES (to be completed if a commercial fundraiser is being employed or retail business conducted)                                           ATTACHMENT A	
COMMERCIAL FUNDRAISER		ADD TO EXISTING LICENCE		
RETAIL BUSINESS		REMOVE FROM EXISTING LICENCE		

NAME OF COMMERCIAL FUNDRAISER / RETAIL BUSINESS	NAME OF CONTACT PERSON	POSITION IN ORGANISATION	
     	     	     	
ADDRESS OF COMMERCIAL FUNDRAISER / RETAIL BUSINESS	
     	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	
     	     	     	

DETAILS OF PROPOSED COLLECTIONS (to be completed for new commercial fundraiser / retail business (Section 9, Regulations) – identify times for children under 12	
Type of collection	Date collection starts	Date collection finishes	Remuneration payable to commercial fundraiser / retail business	Expected income from collection (per financial year)
$	
Personal	     	     	     	     	
Telephone	     	     	     	     	
Written appeals	     	     	     	     	
Internet appeals	     	     	     	     	
Other forms of electronic communication	     	     	     	     	
Collection bins	     	     	     	     	
Other (eg. Fetes, badge days, markets (please list))