Form Post Assessment Form 3 - Notification of Change of Proponent Address and Or Name

Notification of Change of Proponent Address

and/or Company Name

NOTE: This form cannot be used to change a nominated Proponent under Section 38(6a) of the Environmental Protection Act 1986.

This form may be used by a Proponent to notify the Department of Water and Environmental Regulation (DWER) of a change of Address and/or Company Name.

* Required fields

Statement Details* / Statement Number
Proposal Name
Request an action*
Tick appropriate box(es) / ☐ / Change of Address – complete section 1
☐ / Change of Company Name – complete section 2
1.  Details of New Address / Date of Address Change / Click here to enter a date.
Please enter registered street address (this is not a PO Box)
Level / Building
Number / Unit
Street Name
Suburb
State / Postcode
Phone
Please enter postal address
As above / Yes ☐ No ☐
PO Box / Bag Number
Suburb
State / Postcode
2.  Details of New Company Name / Date of Name Change / Click here to enter a date.
New Company Name
Australian Company Number
Former Company Name
Contact details for future correspondence* / Company CEO / Managing Director
Salutations
First Name
Last Name
Position Title
Lodgement Details* / Who should the DWER contact if there is a query about this form?
Name of Contact
Job Title
Email Address
Phone
Date Submitted / Click here to enter a date.
Lodgement / Please submit form electronically to: / For help or more information:
/ Telephone: 08 6364 7000
Or send completed form to: / Email:
Department of Water and Environmental Regulation
Compliance Branch (Ministerial Statements)
Locked Bag 33, Cloisters Square PERTH WA 6850 / Web: www.dwer.wa.gov.au

For Office Use Only

☐ Timeframe for notification reviewed. ☐ ACN confirmed. ☐ 4D and CMS updated. ☐ Proponent correspondence filed (if relevant).

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