Online Form - Application for Certificate of Approval

Health (Miscellaneous Provisions) Act 1911

Health (Public Buildings) Regulations 1992

Premises Details

I, being the owner / agent hereby apply for a Certificate of Approval in respect to

Name of Event*

Premises Number

Street*

Town / Suburb*

Nearest Cross Street*

Dates of Event*

Expected number of people at Event*

Number of male toilets provided*

Number of female toilets provided*

Number of Accessible toilets provided*

Form 5 electrical certification provided?*

YesNo

Certification for rides / seating / tents*

YesNo

Owner / Agent

Address*

Telephone*

Email Address*

I/We declare that all details in this form are true and correct. Please be advised providing false information may be an offense.

Name of Applicant*

Contact Number*

Signature of Applicant*

Date*