Application to Transfer Prescribed
Accommodation
Public Health & Wellbeing Act 2008
Environmental Health Services
Brimbank City Council
PO Box 70
Sunshine Victoria 3020
Ph: 03 9249 4000
http://www.brimbank.vic.gov.au
In order for the application to be assessed you will need to fill in all sections of this form.
Failure to complete the form may delay the transfer process.
Title* Given Name*
Surname*
*
If the proprietor is a company or association the company name will need to be filled in below
or
Company Name (If applicable)
Street Address *
Suburb/Town*
State*
Postcode*
Business Phone* After Hours Phone*
Mobile Phone*
Signature Of Vendor*
Date*
Settlement Date *
Proposed Date of first trade of Business *
Will any alterations to the business be made
Yes
No
(If yes please speak to the Environmental Health Officer to discuss)
SETTLEMENT DETAILS
CURRENT PROPRIETOR DETAILS - VENDOR
PROPRIETOR DETAILS - PURCHASER
Sole Proprietor
Partnership
Company
Title* Given Name*
Surname*
*If the proprietor is a company or association the company name will need to be filled in below
or
Company Name (If applicable)
Home / Registered Address *
Suburb/Town*
State*
Postcode*
Business Phone*
After Hours Phone*
Mobile*
Email address*
Street or Po Box
Suburb/Town
State
Postcode
Title* Given Name*
Surname*
Position*
Contact phone*
PREFERRED CONTACT PERSON
PREFERRED POSTAL ADDRESS FOR CORRESPONDANCE
PREMISES DETAILS
House/ Motel / Hotel - Trading Name*
Street address*
Suburb/Town*
State*
Postcode*
ABN*
Business Telephone*
Number of rooms
Number of Beds - Single
Number of Beds - Double / Queen / King
Number of People at full Occupancy
Please note:
This application is for the above nominated premises for Registration under the Public
Health & Wellbeing Act 2008.
You must contact the Brimbank City Council’s Planning and Building departments (or a
private Surveyor) if you intend to refurbish / renovate the business.
Office Use Only : Debtor Number ________________________ Fee: _____________
Please contact the Environmental Health Department for the appropriate fee.
*** Please contact The Environmental Health department if you are a non for profit organisation that is run by
Volunteers****
I understand and acknowledge that:
-
The information provided in this application is true and complete to the best of my knowledge
-
This application is a legal document and penalties exist for providing false or misleading
information
-
Please ensure that you have completed the form and have attached the requested information.
Failure to do this may
Proprietor Signature
Proprietor Signature
Print Proprietor Name
Print Proprietor Name
Date
Date
The personal information requested on this form is being collected by Council for the purpose of meeting its legal obligations under
the Public Health & Wellbeing Act 2008 and associated or related legislation. The information will be kept confidential and
identifying information will not be disclosed to any person for any other purpose. You may access your own information by
contacting Council’s Environmental Health Services on 9249 4000.
FEES
PRIVACY
DECLARATION BY PURCHASER
In person
Present the completed and signed form to make
payment (eftpos, cash, visa, master card, cheque or
money order)
At one of our Customer Service Centres
301 Hampshire Road, Sunshine
(Brimbank Community & Civic Centre)
Watergardens Town Centre
Station Street, Taylors Lakes,
(Library Building)
By mail (cheque or money order only).
Send the completed and signed form with your
cheque or money order payable to
‘Brimbank City Council
Mail to Brimbank City Council,
PO Box 70, Sunshine Vic 3020
