LEASE/SITE DETAILS (Please Print)

If more than two leases/sites please attach the following details for each additional lease/site on a separate sheet

Block	
		Section			Suburb		

Unit
No.		Street Address 	

Block	
		Section			Suburb		

Unit
No.		Street Address 	

Describe location where no block and section details are available (e.g. for outdoor dining area location)

______________________________________________________________________________________

LESSEE(s) DETAILS  - if more than two lessees please provide details of each additional lessee  (Please Print)

1st Lessee Name	
		2nd Lessee Name		

LESSEE AUTHORISATION

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

•	Pre - application meeting	•	Development Application	•	Application for Reconsideration	

I/we the lessee(s) authorise the person/company (to be known as the Applicant) detailed below: 
•	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 DA or Application for Reconsideration.

APPLICANT DETAILS (Please Print)

Applicant Name	
	Email address 		
OR
Company Name	
	Email address 		

Company Nominees – a Company can list up to three nominees.  The first nominee must be authorised to sign on behalf of the Company

Nominee 1 		Nominee 2 		Nominee 3		

LESSEE(s) DECLARATION if more than two lessees please provide details of each additional lessee on a separate sheet

•	I/we declare that I am/we are the lessee(s) 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
•	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 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;

Applicant Name	
		Company Name 		
					
Signature	
		Date		

LAND CUSTODIAN AUTHORISATION

•	I/we declare that I am/we are the land custodian(s) of the public land or unleased land as described above;
•	I/we authorise the applicant to obtain information in relation to this site through the pre-application process and make an application for development approval.

Delegate Name	
		Agency Name		
					
Signature	
		Date		

Delegate Name	
		Agency Name		
					
Signature	
		Date		

THIS AUTHORISATION DOES NOT CONSTITUTE AN APPROVAL IN PRINCIPLE OR OTHERWISE BY THE LAND CUSTODIAN 
IN RELATION TO THE PROPOSED DEVELOPMENT.

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 158, Canberra City 2601
16 Challis Street Dickson ACT 2602
	
Business Hours: 8.30am - 4.30pm weekdays (excluding Public Holidays)
Email: esddcustomerservices@act.gov.au  
Website:  www.environment.act.gov.au 
Telephone: (02) 6207 1923     TTY: (02) 6207 2622