Charitable Collections
Application for Licence 
(Corporations and Incorporated Associations)

Please indicate whether this application is for a new licence or if you are renewing or amending an existing licence:

New licence 	

Renewal of licence	 	Licence No. ____________	Expiry Date ________

Amend licence	 	Licence No. ____________	Expiry Date ________

Section 1
Applicant’s details i.e. corporation making the application

Name of applicant  _____________________________________________

Address _______________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Details of executive officer to receive correspondence and enquires about the application for the corporation:

Mr 	Mrs  	Ms 	Miss 	Other _______________________

Surname ______________________________________________________

Given names ___________________________________________________

Address _______________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Relationship to/position in corporation _______________________________

Section 2.
Is the corporation externally administered? i.e
(a)	is it being wound up?      Yes       No 
(b)	has a receiver been applied?     Yes       No 
(c)	is it under administration?     Yes       No 
(d)	is it subject to a deed of company agreement?     Yes       No  
(e)	has it entered into a compromise arrangement with another person, the administration of which has not been concluded?     Yes       No 

Details of the purpose for which the licence is sought.  Please include the name of the charity to which benefits/proceeds will go to, if the charity is not the applicant corporation.
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

If the charity to which benefits/proceeds will go is not the applicant, has the collection been approved by the charity?

Yes 		No 

Please attach written authorisation by the charity for the applicant to undertake this collection.

Section 3
Please indicate how the collection will be undertaken by the applicant and provide details of the time period during which the collection will be conducted.  (If the collection is to involve more than one form, please provide relevant information for each form)

 Telephone

From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	mm	yr

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

 Door to door 
From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

 Clothing bins
From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

 Letter
From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

 Internet
From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

 Other (please specify) _________________________________________

From: _____/____/______ to ____/____/______
	dd	 mm	yr 	dd	 mm	yr

What time of day will the collection be undertaken?_____________________

_____________________________________________________________________________________________

How will the collection be supervised? 

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________
(Please provide details in an attachment if more room is required)

How will the benefits/proceeds raised from the collection be distributed?
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________
(Please provide details in an attachment if more room is required)

Section 4
Will a commercial fundraiser be engaged for any aspect of the collection?

Yes 		No 

If yes, please provide details:

Name of Corporation _____________________________________________

Contact Person _________________________________________________

Position _______________________________________________________

Address _______________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________
Please provide details of the activity to be undertaken by the commercial fundraiser, including the time period that the activity will be carried out (if different to the information provided in Section 3). 
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please provide details of remuneration payable to the commercial fundraiser or how the remuneration will be calculated.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

(If more than one commercial fundraiser is to be engaged please provide an attachment with relevant details for all other fundraisers)

Section 5
Will any retail business be engaged for any aspect of the collection?

Yes 		No 

If yes, please provide details:

Name of Business _______________________________________________

Contact Person _________________________________________________

Position _______________________________________________________

Address _______________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Please provide details of the activity to be undertaken by the retail business, including the time period that the activity will be carried out (if different to the information provided in Section 3). 
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please provide details of remuneration payable to the retail business or how the remuneration will be calculated.
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

(If more than one retail business is to be engaged please provide an attachment with relevant details for all other businesses)

Section 6
Has the corporation held a licence to carry out a collection for charitable purposes in the past?

Yes 		No 

If yes, please provide details of the nature of previous activities and the period of time over which the activities were carried out.  
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Has the corporation, an executive officer or an associate of the corporation ever had a licence to carry out a collection for charitable purposes suspended or cancelled?  NB.  A person is an associate in relation to an application for a licence if the person can, or will be able to, have significant influence over, or in relation to the carrying out of a collection to which this application relates.

Yes 		No 

If yes, please provide details.
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________
Has an executive officer or an associate of the corporation ever been convicted (in the ACT or elsewhere) of an offence involving fraud or dishonesty?  NB.  A person is an associate in relation to an application for a licence if the person can, or will be able to, have significant influence over, or in relation to the carrying out of a collection to which this application relates.

Yes 		No 

If yes, please provide details.
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Section 7

•	_______________________________________________________ 
	(Corporation/Associationl name)

warrants that:

i.	the information contained in this application is true and correct; and

ii.	it makes this application and will be responsible for the collection.

•	The Applicant acknowledges that:

i.	the authorisation of a licence will be subject to the requirements of the Charitable Collections Act 2003 and the Regulations of the Charitable Collections Act 2003, including any condition which may be imposed under them;

ii.	as licensee, the corporation will be responsible for providing a report on the collections conducted under the licence in the format provided at Appendix 1, and any other information that may be required under the license conditions, within the timeframe stipulated under the licence conditions; and 

iii.	an auditor’s report of accounts and records kept for the collections conducted under the licence may be also required.

Section 8

This form must be executed by the Applicant by one of the following methods:

Incorporated Associations:

Option 1:  Common Seal

The Common Seal of the Applicant is affixed in accordance with its rules or constitution:

____________________________
Common Seal
affixed in the presence of:

____________________________		____________________________
Signature of Authorised Officer			Signature of Authorised Officer

____________________________		____________________________
Print Name					Print Name

Option 2: Without Common Seal

Signed for and on behalf of the Applicant by the following persons who certify that they are authorised to sign on behalf of the Applicant:

Signature of Authorised Officer: ____________________________________

Full Name of Authorised Officer:____________________________________

Position: _________________________________   Date ________________

Signature of Authorised Officer: _____________________________

Full Name of Authorised Officer:____________________________

Position: _________________________________   Date ________________

Companies:

Signed for and on behalf of the Applicant by:

(a)	2 directors; or
(b)	a director and a company secretary; or
(c)	the sole director (who is also the sole company secretary) and a witness; or
(d)	an attorney and witness and, if signed by this method, the attorney certifies that he/she has no notice of revocation of the power of attorney.

…………………………………………	………………………………………….
Signature of Director/Attorney	Witnessedby:Signatureof Director/Secretary/Witness

…………………………………………	………………………………………….
Print Name 					Print Name

…………………………………………	………………………………………….
Print Position					Print Position

Date: …………………………………	Date: ………………………………..