IMPORTANT INFORMATION
This form is to be used when surrendering a licence under Section 29 of the Charitable Collections Act 2003 (the Act). Licensees should be aware of their responsibilities under the Act. The legislation and regulation can be accessed at www.legislation.act.gov.au.  
Licensees surrendering a Charitable Collection licence are required to provide finalised accounts within 120 days after the surrender date by completing the Financial Reports to the Director-General for a Charitable Collection form. Where the amount of the collection from ACT residents is less than $50,000 please complete the form, including the collection details. Where the amount of the collection from ACT residents is $50,000 or more please complete the form and attach audited statements of the collection.
If the collection includes monies collected from other Australian States and Territories it is permissible to report on the whole collection if you are unable to distinguish between that collected from the ACT and that collected elsewhere.
The Licensee must return the original licence to Access Canberra.
You may obtain further information and forms at www.accesscanberra.act.gov.au.	
PRIVACY INFORMATION
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 Information Privacy Act 2014). The Director-General may provide additional information to law enforcement agencies and authorised organisations that have legal authority to request information under prescribed circumstances.	
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.	
LODGEMENT AND CONTACT INFORMATION	
LODGEMENT AND CONTACT INFORMATION	

Email:
accesscanberra.bil@act.gov.au
	
Post:
Access Canberra
Charitable Collections Licensing
GPO Box 158
Canberra, ACT 2601	
In Person:
Please visit www.act.gov.au/accessCBR
Or call 132281 to find an 
Access Canberra Shopfront	

	
TRANSLATING AND INTERPRETING SERVICE
If you require further information or need advice, a language assistance service is available by phoning the 
Translating and Interpreting Service (TIS) on 13 14 50.	

LICENCE DETAILS	
	
NAME OF LICENSEE	LICENCE NUMBER	DATE SURRENDERED 	LICENCE ATTACHED	
			Yes		No* (see page 3)		
	
LICENSEE / CONTACT / NOMINATED PERSON DETAILS	
TITLE	FULL NAME OF NOMINATED PERSON / CONTACT	POSITION HELD WITHIN ORGANISATION	
			
ADDRESS	SUBURB	POSTCODE	
			
PHONE NUMBER	FAX NUMBER	
		
EMAIL ADDRESS	
	
SIGNATURE OF NOMINATED PERSON OR CONTACT OFFICER	
Licensee’s name in full:	
Signature:	
Date:	

STATEMENT FOR LOST, STOLEN OR DESTROYED LICENCE 
(If the licence is not attached, you must complete this statement)	
	
I, (full name)	
make the following statement regarding the loss, theft or destruction of the licence detailed above:

	
Signed:	Date:	
It is an offence to make a false or misleading statement, give false or misleading information or provide a false or misleading document (see Criminal Code 2002, pt 3.4)