IMPORTANT INFORMATION
This form is to be used when applying for a replacement licence under the Charitable Collections Act 2003 (the Act) when your licence is lost, stolen or destroyed. Licensees should be aware of their responsibilities under the Act. You can access the legislation and regulation at www.legislation.act.gov.au.  
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.
Licences cannot be transferred to another entity.
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
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	
	
LICENCE NUMBER	COMMENCEMENT DATE
(Office use only)	EXPIRY DATE
(Office use only)	TERM OF LICENCE
(Office use only)	
				
TYPE OF LICENCE	
Individual		Unincorporated		Corporation		Incorporated body		
	
NAME OF ORGANISATION / REGISTERED NAME IF INCORPORATED (If incorporated, please provide copy of the certificate of incorporation)	
	
APPLICANT / CONTACT / NOMINATED PERSON DETAILS (Main contact with Access Canberra)	
All applicants must complete this section.
•	An individual applicant must provide their details
•	An incorporated organisation must provide the name and details of a contact person
•	Unincorporated organisations must provide the name of the nominated person. The nominated person is the holder of the licence.	
TITLE	FULL NAME OF NOMINATED PERSON / CONTACT	POSITION HELD WITHIN ORGANISATION	
			
ADDRESS	SUBURB	POSTCODE	
			
PHONE NUMBER	FAX NUMBER	
		
EMAIL ADDRESS	

STATEMENT FOR LOST, STOLEN OR DESTROYED LICENCE 
(If the licence or permit has been lost, stolen, or destroyed, 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)