Charitable Collections
Application for Licence (Unincorporated body)

This form must be completed in full by an executive officer of the applicant unincorporated body (body).

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
Name of body __________________________________________________

Address _______________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Details of executive officer (ie, a person who is concerned with, or takes part in, the unincorporated body’s management) completing this application on behalf of the applicant body 

Mr 	Mrs  	Ms 	Miss 	Other _______________________

Surname ______________________________________________________

Given names ___________________________________________________

Address _______________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Is the executive officer completing this application form the nominated person for the applicant body in relation to the license?

Yes 		No 

If no, please prove details of the “nominated person” and ensure that the nominated person completes and signs the declaration on p.7.

Mr 	Mrs  	Ms 	Miss 	Other _______________________

Surname ______________________________________________________

Given names ___________________________________________________

Address _______________________________________________________

Telephone __________________		Fax _____________________

Email ___________________________________________

Section 2.
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 body.
______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

______________________________________________________________

If the charity to which benefits/proceeds will go to is not the applicant body, 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 Organisation____________________________________________

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 applicant body been issued 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 applicant body, executive officer or an associate of the body, or the “nominated person” ever had a licence to carry out a collection for charitable purposes suspended or cancelled (in the ACT or elsewhere)? NB.  A person is an associate in relation to an applicant 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 body, or the “nominated person” 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 applicant 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
Executive Officer

•	I, _________________________________ declare that the information 
(executive officer’s name in full)
contained in this application is true and correct.

•	I understand 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.	if at any time there is no nominated person in relation to the licence, that the executive officer of this body will be taken to be the licensee;
iii.	the licensee is 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 licence conditions, within the timeframe stipulated under the licence conditions; and 
iv.	an auditor’s report of accounts and records kept for the collections conducted under the licence may be also required.

Signature of executive officer: _____________________________________

Office held: _________________________________   Date _____________

Full Name of Witness:___________________________________________

Position held: __________________________________   Date ___________

Address:_______________________________________________________

Signature: _____________________________________________________

Nominated Person

•	I, _______________________________________________________ 
	(nominated person’s full name)
declare that the information contained in this application is true and correct and that I have given my consent to being the person nominated by 
________________________________________ in relation to the licence. 
			(Unincorporated body)

•	I understand 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, I 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 licence 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.

Signature of nominated person: ____________________________________

Position held:___________________________________   Date __________

Full Name of Witness:___________________________________________

Position held: __________________________________   Date ___________

Address:_______________________________________________________

Signature: _____________________________________________________