Application for Reconsideration
	
•	Refusal of Development Application		
For applications assessed in the Merit and Impact assessment tracks only	Insert Development Application Number to which this application relates: 

20………………..	
				
•	Conditions of Approval		
For applications assessed in the Code, Merit and Impact assessment tracks	Insert Development Application Number to which this application relates: 

20………………..	
				
•	Refusal of an Amendment
		For amendments assessed in the Merit and Impact assessment tracks only	Insert amendment number to which this application relates: 

20………………..	
				
•	Amendment approved with conditions		For amendments assessed in the Code, Merit and Impact assessment tracks	Insert amendment number to which this application relates: 

20………………..	

Please specify grounds on which reconsideration of the original decision is sought:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Lease/Site Details Please Print

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

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 Number (ACN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

Lessee (Property Owners) Details Please Print

1st Lessee’s Details (or Government Land Manager)

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company Number (ACN)		
		
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.

Lessee (Property Owners) Details continued 

2nd Lessee’s Details (or Government Land Manager)

Surname	
		First Name		
		
Company Name	

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

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

Provision of Notice of Reconsidered Decision 

Your notice of reconsidered decision will be returned via email.  Please ensure you have provided an email address.

Documentation Supporting Application

Have you provided documentation to support your application?	•	NO
•	YES	
		
Have you amended your plans to support your application?
	•	NO
•	YES	

If YES  
Please provide a copy of plans with this application and describe the impact (if any) on other conditions of approval.

	

	

	

	

Exclusion from Public Inspection

In accordance with the requirements of Sections 28 and 30 of the Planning and Development Act 2007 the 
Planning and Land Authority must make the details and associated documents relevant to a development application available for public inspection.

If you wish to apply to have all or part of this development application excluded from public inspection you must meet the requirements of Section 411(5) or 412(1) of the Planning and Development Act 2007.

Exclusion from Public Inspection Requested	•	YES
•	NO	
		
If Yes – please indicate under which section of 
Planning & Development Act 2007	•	S.411(5)  Restriction on Public Availability
•	*S.412(1) Restriction on Public Availability 
                     SECURITY

Please specify the information to be excluded from public inspection and provide reasons for exclusion:

* if exclusion is requested under Section 412(1) a letter, signed by a justice Minister, certifying this request satisfies the requirements of the Planning and Development Act 2007 must accompany this application.

Conflict of Interest Declaration

Does the applicant or lessee have any association with EPD staff?	•	NO
•	YES	
If YES please provide details:	

NOTE: There are penalties for deliberately giving false and misleading information. The Planning and Land Authority or Minister may revoke an approval if satisfied that the approval was obtained by fraud or misrepresentation.

Applicant and Lessee Declaration

I/we the undersigned, declare that this application is accompanied by all of the required information and or documents and understand that the documentation provided on CD/DVD or via electronic lodgement process (email or internet) will be considered to be the relevant documentation associated with this application;

I/we understand that the information submitted with this application form will undergo a documentation check.  I/we understand that this application will be considered lodged once the relevant application fees have been paid;

I/we hereby authorise ACT Government officers to access the subject property(s) for the purpose of evaluating the proposal;

I/we the undersigned (lessee) appoint the applicant whose name and signature appear below to act on my/our behalf in relation to this application.  This authorises the applicant to pay for 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 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 Signature	
	Date		
				
2nd Lessee Signature	
	Date		
				
Govt Land Managers Signature 
(unleased land only)	

	Date		
				
Delegate of the Planning and Land Authority 
(unleased land only)	

	Date		

Privacy Notice
The personal information on this form is provided to the Environment and Planning Directorate (EPD) to enable the processing of your application. The collection of personal information is authorised by the Planning and Development Act 2007.  If all or some of the personal information is not collected EPD cannot process your application. 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. The personal information you provide may be disclosed to Australian Bureau of Statistics, ACT Revenue Office, the Registrar General’s Office, ACTEW Corporation, ActewAGL, Territory and Municipal Services Directorate and other Government agencies with a direct interest in the development assessment process.  The information may also be disclosed where authorised by law or court order, or where the Directorate reasonably believes that the use or disclosure of the information is reasonably necessary for enforcement-related activities conducted by, or on behalf of, an enforcement body. EPD’s Information Privacy Policy contains information about how you may access or seek to correct your personal information held by EPD, and how you may complain about an alleged breach of the Territory Privacy Principles. The EPD Information Privacy Policy can be found at www.environment@act.gov.au 

Contact Details:
Environment and Planning Directorate
Customer Service Centres
GPO Box 158, Canberra City 2601
8 Darling Street Mitchell, ACT 2911
16 Challis Street Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)
Phone: (02) 6207 1923	TTY: (02) 6207 2622
Email: epdcustomerservices@act.gov.au	Website: www.environment@act.gov.au