Given Name/s (In full) *

Surname *

Date of Birth *

Home Phone *

Business Phone

Mobile Phone *

Email Address

Residential Address *

Postal Address (If different from above)

I would like to change:

Individual NameIndividual Address

New Name Details

A separate form must be completed for each individual.

The personal information requested on this form is being collected by Council to maintain an accurate Name and Address Register. The personal information will be used solely by Council for that primary purpose or directly related purposes. The applicant understands that the personal information provided is for Council records and that they may apply to Council for access and or amendment of their information.

New Given Name/s (In full)

New Surname

Please select which documentation is supporting this application: required *

Marriage CertificateDeed Poll DocumentationCertified copy of drivers licenceOther

Other

File Upload (1)

Browse

File Upload (2)

Browse

File Upload (3)

Browse

File Upload (4)

Browse

File Upload (5)

Browse

Accounts with Council

Do you have an Aqua Energy Membership? *

Do you have any outstanding/unpaid infringements? *

Address Details

Rates Assessment Number

OLD Residential Address

OLD Postal Address (If different from above)

NEW Residential Address

NEW Postal Address (If different from above)

Is this new address for all account/correspondence? *

Please provide an explanation of change required:

Would you also like to change address details for an additional person other than listed above (eg. a partner)? *

Additional Applicant

Person 2 Given Name/s

Person 2 Surname

Person 2 Date of Birth

Person 2 Home Phone

Person 2 Business Phone

Person 2 Mobile Phone

Person 2 Email Address

Relationship to Applicant 1

Assessment Number *

Property Address *

Other Council Accounts

Do you have an Aqua Energy Membership? *

Do you have any current or unpaid infringements? *

Do you have any active planning applications? *

Do you have an Account with Council for Accounts Payable/Receivable? *

Do you have a Health/Food Premises Registration? *

Additional Comments

Are there any animals registered to the applicant? *

Animal (1)

Animal (1) Number *

Animal (1) Name *

Is this animal (1) kept at your new residential address? *

Would you like to add a second animal?

Animal (2)

Animal (2) Number *

Animal (2) Name *

Is this animal (2) kept at your new residential address? *

Would you like to add a third animal?

Animal (3)

Animal (3) Number *

Animal (3) Name *

Is this animal (3) kept at your new residential address? *

Declaration

Name of person completing this form *

I have completed all required sections on this form. I declare that all the information provided on this form is true and correct and understand that it is an offence to provide false or misleading information. *

I acknowledge that if I have an active BPAY View or email delivery registration, I am responsible for altering/cancelling this service. *

I acknowledge Wellington Shire Council's Privacy Statement. *