Signed, sealed and delivered for and on behalf of the State of Victoria through the [Department’s name] by its authorised representative in the presence of: ........................................................... ........................................................... Witness Authorised Representative ........................................................... ........................................................... Name of Witness (print) Name of Authorised Representative (print) Date: _____ / _____ / _____ The terms of this document are accepted and agreed by the Proponent. [Insert execution block] Proponent’s
Signed, sealed and delivered for and on behalf of the State of Victoria through the [Department’s name] by its authorised representative in the presence of: ........................................................... Witness ........................................................... Name of Witness (print) ........................................................... Authorised Representative ........................................................... Name of Authorised Representative (print) Date: _____ / _____ / _____ The terms of this document are accepted and agreed by the Proponent. [Insert Proponent’s execution block]