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 DA 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 provided to the Environment, Planning and Sustainable Development 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 EPSDD 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. EPSDD’s Information Privacy Policy contains information about how you may access or seek to correct your personal information held by EPSDD, and how you may complain about an alleged breach of the Territory Privacy Principles. The EPSDD Information Privacy Policy can be found at www.environment.act.gov.au 

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