Application form to transfer prescribed ... - City of Whittlesea

Civic Centre25 Ferres BoulevardSOUTH MORANG 3752Locked Bag 1BUNDOORA MDC 3083Health Services Enquiries: 9217 2277General Enquiries: 9217 2170Health Services Fax: 9409 9863Email: PublicHealth@whittlesea.vic.gov.auTTY:(03) 133677 (ask for 9217 2170)www.whittlesea.vic.gov.auABN 72 431 091 058Application for Transfer Registration of PrescribedAccommodationPublic Health and Wellbeing Act 2008 (Vic)Reference number::Office Use OnlyTransfer FeeReceipt NoPlease use this form to apply to the City of Whittlesea Council to transfer a health premises from the current proprietor to the newproprietor. Please note that the transfer is not official until Council has approved this applicationApplicant name:This section to be completed by existing proprietorContact numbers: Bus: Home: Mob:Premises address:Fax:Email:ACN:ABN:Date:Printed name of existing proprietor: ______________________________ / ______________________________Signature of existing proprietor:_______________________________ / ______________________________Date / / Date / /In the case of a corporate body, the signing officer must execute under a company seal stating his/her position of authorityApplicant name:Business trading name:This section to be completed by Proposed (New) proprietorContact Numbers:Premises address:Bus: Home: Mob:Fax:Email:Postal address:Type of business premises:Type of accommodation (Please tick): Rooming house Hostel Holiday camp Hotel or motel Student dormitoryDeclaration Residential accommodation Other (specify)I understand and acknowledge that:The information provided in this application is true and complete to the best of my knowledgeThis application form is a legal document and penalties exist for providing false or misleading informationI am over 18 years at the time of completing this applicationPrinted name of applicants: _____________________________/___________________________________Signature of applicants: ______________________________/_____________________________________Public Health & Wellbeing Act Transfer Application – reviewed June 2012

Date / / Date / /In the case of a corporate body, the signing officer must execute under a company seal stating his/her position of authorityFeesPlease contact Council's Health Services for the transfer fee for health premises or refer to http://www.whittlesea.vic.gov.auIf paying by credit card via post, ensure you include a completed Credit Card Payment Authorisation form, which you can downloadfrom the City of Whittlesea website.MailCheque/money order only, made payable to “City of Whittlesea”.Mail payment and invoice to: City of Whittlesea, Locked bag 1 MDC,Bundoora, 3083In person• Please present notice intact to the Cashier.• Pay by cash, cheque, money order or EFTPOS (including creditcard) at the Civic Centre, 25 Ferres Boulevard, South Morang.Bankcard, Visa card, Mastercard.Credit cardMasterCard or VisaTelephone: 9217 2277Office hours are 8.30am to 5.00pm Monday to Friday, except PublicHolidaysPayment detailsPrivacy statementCouncil is collecting the information on this form for the purpose of administration and enforcement of the Public Health and WellbeingAct 2008 (Vic). The information will be used solely by Council for the primary purpose or directly related purposes. As required underthe Public Health and Wellbeing Act 2008 (Vic), this information will be kept in a register (computerised database). In accordance withthe Public Health and Wellbeing Act 2008 (Vic) a copy of this information must be made available free of charge to any person whorequests it. You may access this information by contacting Health Services on 9217 2277.