Contact person for correspondence Provide the details of the person who will be the contact for any enquiries about this application. Title Family Name Given names (Mr, Mrs, etc) Email address Business hours telephone number Fax number Postal address Same as licensee’s postal address in question 3 Same as children’s service premises address in question 5 Same as children’s service postal address in question 6 Different postal address specified Building name (if applicable) Unit, floor, street number and street name or PO box Suburb/Town State Postcode Declaration and signature I declare that: the information in this application and any attachments are true and correct; all persons newly nominated to exercise management or control over the children’s service have been listed in this application; the primary nominee and all approved nominees who will manage or control the children’s service in the licensee’s or approved provider’s absence have either been previously approved as fit and proper by the Secretary or Delegate of the Department within the last 5 years or the required fit and proper documentation has been provided with this application; all nominees who will or may manage or control the children’s service are fit and proper persons in accordance with the Children’s Services Act 1996 and Children’s Services Regulations 2009; I have assessed all proposed accepted nominees as fit and proper in accordance with the Children’s Services Act 1996 and the Children’s Services Regulations 2009, including reviewing: a current assessment notice (Working With Children Check) or a current certificate of registration as a teacher − (Victorian Institute of Teaching registration); relevant qualifications or certificates of completed training; − any mental or physical condition that may impair their ability to operate or exercise management or control over a − children’s service; and information from at least 2 referees provided by the person to attest to their integrity, good character and repute. − Who must sign: Individuals: The individual licensee or approved provider. Company: Two directors of the company, or a director and company secretary, or if sole proprietor the sole director. Incorporated association: The Public Officer and one other member of the management committee. Cooperative: Two directors of the cooperative, or a director and one other officer of the cooperative. Partnership: A managing partner who is authorised to sign on behalf of the partnership. This signature binds all partners. Corporation/ Government School Council: Signed in accordance with rules of the corporation/council. Signature Printed name Position (if body corporate) Date X
Contact person for correspondence Provide the details of the person who will be the contact for any enquiries about this application. Title (Mr, Mrs, etc) Family Name Given names Email address Business hours telephone number Fax number Postal address Same as licensee’s postal address in question 3 Same as children’s service premises address in question 5 Same as children’s service postal address in question 6 Different postal address specified Building name (if applicable) Unit, floor, street number and street name or PO box Suburb/Town State Postcode Declaration and signature I declare that: the information in this application and any attachments are true and correct; all persons newly nominated to exercise management or control over the children’s service have been listed in this application; the primary nominee and all approved nominees who will manage or control the children’s service in the licensee’s or approved provider’s absence have either been previously approved as fit and proper by the Secretary or Delegate of the Department within the last 5 years or the required fit and proper documentation has been provided with this application; all nominees who will or may manage or control the children’s service are fit and proper persons in accordance with the Children’s Services Act 1996 and Children’s Services Regulations 2009; I have assessed all proposed accepted nominees as fit and proper in accordance with the Children’s Services Act 1996 and the Children’s Services Regulations 2009, including reviewing: − a current assessment notice (Working With Children Check) or a current certificate of registration as a teacher (Victorian Institute of Teaching registration); − relevant qualifications or certificates of completed training; − any mental or physical condition that may impair their ability to operate or exercise management or control over a children’s service; and − information from at least 2 referees provided by the person to attest to their integrity, good character and repute. Who must sign: Individuals: The individual licensee or approved provider. Company: Two directors of the company, or a director and company secretary, or if sole proprietor the sole director. Incorporated association: The Public Officer and one other member of the management committee. Cooperative: Two directors of the cooperative, or a director and one other officer of the cooperative. Partnership: A managing partner who is authorised to sign on behalf of the partnership. This signature binds all partners. Corporation/ Government School Council: Signed in accordance with rules of the corporation/council. Signature Printed name Position (if body corporate) Date X
appnomceasing.docx