Application for Registration of Health Premises Public Health and Wellbeing Act 2008 Fields marked with an asterisk (*) are mandatory and must be completed. Council Specific Information Environmental Health Officer, Hindmarsh Shire Council, PO Box 250, NHILL,V IC 3418 Applicant Details Proprietor Is this proprietor a contract for this application? Yes/No complete the If ‘no’ please (If there is more than one proprietor of the business, complete details for each below) Contact section below Title* Surname* Given Names * ABN ACN Business Name Company Name Address PO Box GPO Box Private Bag Locked Bag RRN RSD Street Address/ Postal Address* Suburb / Town* State * Postcode * Please provide at least one phone number and include the area code * Business Phone After hours phone Business Fax ( ) ( ) ( ) ( ) Email Proprietor 2 (if applicable) Title* Surname* Given Names * ABN ACN Business Name Company Name Address PO Box GPO Box Private Bag Locked Bag RRN RSD Street Address/ Postal Address* Suburb / Town* State * Postcode * Please provide at least one phone number and include the area code * Business Phone After hours phone Business Fax
Application for Registration of Health Premises Public Health and Wellbeing Act 2008 Fields marked with an asterisk (*) are mandatory and must be completed. Council Specific Information Environmental Health Officer, Hindmarsh Shire Council, PO Box 250, NHILL,V IC 3418 Applicant Details Proprietor Is this proprietor a contract for this application? Yes/No (If there is more than one proprietor of the business, complete details for each below) If ‘no’ please complete the Contact section below Title* Surname* Given Names * ABN ACN Business Name Company Name Address PO Box GPO Box Private Bag Locked Bag RRN RSD Street Address/ Postal Address* Suburb / Town* State * Postcode * Please provide at least one phone number and include the area code * Business Phone After hours phone Business Fax ( ) ( ) ( ) ( ) Email Proprietor 2 (if applicable) Title* Surname* Given Names * ABN ACN Business Name Company Name Address PO Box GPO Box Private Bag Locked Bag RRN RSD Street Address/ Postal Address* Suburb / Town* State * Postcode * Please provide at least one phone number and include the area code * Business Phone After hours phone Business Fax