/ Pre-purchase Inspection of a
Food Premises
All correspondence to:
PO Box 51
Ivanhoe VIC 3079
Ph: 9490 4222
Fax: 9499 9475
ABN 16 456 814 549 / Service Centres
Greensborough:9-13 Flintoff Street
Ivanhoe:275 Upper Heidelberg Road
Rosanna:44 Turnham Avenue

I Hereby Request the following for a Food Premises:-

Pre-Purchase Inspection:

Request for pre-purchase inspection & report – within 5 working days Fee: $260.00
*Please mark request “Urgent Attention Required” Includes GST

Request for pre-purchase inspection & report – within 10 working days Fee: $170.00

IncludesGST

Part 1. Applicant Details
Name of Applicant
Name of person who the information or documents to be disclosed or published
Postal Address
Where the report will be sent
Telephone / Fax:
Email:
Signature:
By signing this you acknowledge that
you have read the Privacy Information* / Date:
Part 2. To be Completed by Current Proprietor
I / We, the proprietor/s of the premises named in “Part 2. To be Completed by Current Proprietor”HEREBY CONSENT the Banyule City Council to the disclosure of any information and the publication of any documents in your possession or power relating to the said food premises whether the information or the documents were obtained in connection with the administration of the Food Act 1984 or otherwise to the person names in “Part 1 Applicant Details”.
Current Proprietor Name:
Individual or company name
Current Trading Name:
Premises Address:
Signature/s:
In the case of a company, the person signing must state their position in the company / Date:
Date:

Note: All Proprietors of the Food Premises Must Sign This Consent

Health Services / CD15194 Food Prepurchase Inspection Consent Form / Last Amended: 1 July 2016 / Page 1 of 1

*Privacy Information

Council respects all personal and confidential information you give and will do everything possible to protect information from unauthorised access, loss or misuse. Information collected from you is required for the delivery of Council Services in accordance with Council’s powers, functions and purposes under the Local Government Act 1989 and other relevant legislation. It may also be used by Council to conduct research and customer satisfaction surveys so that we may better understand community needs and can improve service delivery. Should you need to change or access your personal details, please contact Customer Service on (03) 9490 4222.

Office Use Only

Registration No: 50. / Area: / Code.T126 A/C:41070.0021.7006
Health Services / CD15194 Food Prepurchase Inspection Consent Form / Last Amended: 1 July 2016 / Page 1 of 1