APPLICATION FOR LICENSEE TO CHANGE NAME, ADDRESS OR PHONE CONTACT
Charitable Collections Act 2003
Charitable Collections Regulation 2003
		
PURPOSE 

This form is to be used for the purpose of the Licensee change the name, address or telephone number in accordance with 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
•	Licensees should be aware of their responsibilities under the Charitable Collections Act 2003.  
•	Licensees are required to notify the Director-General within 7 days of the change of name, address or telephone number as shown on the licence.
•	If the name of the licensee has changed please attach evidence of the name change.
•	Licenses cannot be transferred to another entity.
•	The Licensee must return the original licence to the Director-General for amendment.
	
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 LICENSEE TO CHANGE NAME, 
ADDRESS OR PHONE CONTACT
Charitable Collections Act 2003
Charitable Collections Regulation 2003	

LICENCE NUMBER	FULL NAME OF APPLICANT / CONTACT PERSON	LICENCE ATTACHED	
		 Yes	 No	
ADDRESS OF APPLICANT/CONTACT PERSON	
	PHONE		
	FAX		
	EMAIL		

DETAILS PRIOR TO CHANGE	

LICENCE NAME 	
		
ADDRESS (Property name, unit, flat, room no, street number, street name, city/suburb/town, postcode)	
	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	

DETAILS AFTER CHANGE	

NEW LICENCE NAME (if applicable)	
		
ADDRESS (Property name, unit, flat, room no, street number, street name, city/suburb/town, postcode)	
	
PHONE CONTACT	FAX CONTACT	EMAIL CONTACT	

EVIDENCE OF CHANGE OF NAME ATTACHED? (if applicable)	 Yes	 No	

STATUTORY DECLARATION BY LICENSEE IF THE LICENCE IS NOT ATTACHED TO THE APPLICATION	

I …………………………………………………………………………….of……………………………………………………………………….
(Name)                                                                                         (Address)
………………………………………………………………………………………………………………………..
(Occupation)

hereby declare that the Charitable Collection Licence No                                  issued to ……………………………………………………has been lost, mislaid or destroyed.

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statement in this declaration is true in every particular.

Declared at ………………………………………………on the ……………………day of ……………………………………….20

Signature of person making the declaration ………………………………………………………………………………………….

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)