Postal AddressRatesInternet

PO Box 159Ph: 07 3205 0555

Caboolture QLD

ABN:92 967 232 136

Applicant details:

Individual/s

Applicant 1 details:

Title: Mr Mrs Ms Miss

Given names: / Surname:
Please list any other name/s you are known by (if applicable):
Old residential address:
Old postal address:

New contact details:

New residential address:
New postal address:
Home phone: / Mobile phone:
Work phone: / Email address:

Applicant 2 details:

Title: Mr Mrs Ms Miss

Given names: / Surname:
Please list any other name/s you are known by (if applicable):
Old residential address:
Old postal address:

New contact details:

New residential address:
New postal address:
Home phone: / Mobile phone:
Work phone: / Email address:

OR

Company/Organisation

Company/Organisation name:
Business/trading name:
ABN:
Old street address of registered office:
Old postal address:

New contact details:

New street address of registered office:
New postal address:
Work phone: / Email address:
Contact person:

Records/accounts with council:

Please provide details of all records/accounts you have with council that require updating.

Rate/s – Please attach details of additional properties if required.

Note: if you are registered for eMBRC to receive rates notice via email and would like to deregister and have future rates notices posted OR update your email address visit . If you currently receive rates notices via BPay View and would like to deregister and have future rates notices posted, delete Moreton Bay Regional Council as a biller in your internet banking.

Assessment number (as per your rates account) / Property location/address

Animal registration (dogs and/or cats) – Please attach details of additional animals if required.

Animal reference number OR registration tag number / Name of animal
Is this animal moving to your new residential address? Yes No
Is this animal moving to your new residential address? Yes No
Is this animal moving to your new residential address? Yes No
Is this animal moving to your new residential address? Yes No

If you have indicated no to any of the above animals, please specify property where animals will now reside:

Do you currently hold any licences/approvals with council? No Yes – if yes, please provide details of the licence below.

Please attach details of additional licences if required.

This includes: Animal breeders approval; Approval to keep animals in accordance with the local law; Restricted dog breed permit; Advertising signs; Backflow prevention devices; Caravan park and camping grounds; Display of good on council controlled land; Food business licence; Environmentally Relevant Activity (ERA); Itinerant vending; Outdoor dining; Permitted business in a public place; Personal appearance service; Sale of goods on council controlled land; Shared facility accommodation; On-site sewerage facilities (including HSTP, septic, holding tank and composting system).

1. Type of licence (e.g. Food business):
Licence number: / Is postal address to be updated? Yes No
Licencee name:
2. Type of licence (e.g. Food business):
Licence number: / Is postal address to be updated? Yes No
Licencee name:
3. Type of licence (e.g. Food business):
Licence number: / Is postal address to be updated? Yes No
Licencee name:

Customer summary:

I acknowledge that my contact details will be updated only for the records/accounts listed on this application.

Signature: / Date:

Privacy statement

MoretonBay Regional Council is collecting your personal information for the purpose of updating council’s records. The collection of this information is authorised under the Local Government Act 2009. Your information will not be given to any other person or agency unless you have given us permission or we are required by law.

Page 1 of 2