Application for Licence Pursuant to Section 6A Collection Agent's

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					                                                                                            Application for Licence
                                                                                             Pursuant to Section 6A
                                                                                         Collection Agent’s Licence
                                                                                          Collections for Charitable Purposes Act 1939
                                                                                                            Lottery Licensing (ABN 15 088 976 178)
                                                                                                 Level 3, East Wing 50 Grenfell St Adelaide SA 5000
                                                                                                                      GPO Box 672 Adelaide SA 5001
  Office use only                                                                                                   t 08 8226 8500 f 08 8226 8588
                                                                                                            e lottery@agd.sa.gov.au w olgc.sa.gov.au
  Date received      ________________             Licence No    CA    ______________
  Expiry date        ________________

  Assessor           ________________             Granted by    __________________

   No Fee Applicable

   New Licence/Renewal of Licence
   Please indicate if this application is for a:
         New licence                 Renewal of existing licence

   Please complete all Items

   Item 1                Applicant on behalf of organisation

         Mr                  Mrs                  Miss               Ms           other _________________

   Contact                                  ________________________________________________________________________________


   Telephone numbers                           Work       ______________________________

                                               Fax        ______________________________       Mobile        ____________________________

   Email                     _________________________________________________

   Date licence number is required __________________________

   Licence to be sent via:                Post              Email          Fax
   (tick ( ) one only)


   Item 2
   Name of organisation                     ______________________________________________________________________________

   Trading name                             ______________________________________________________________________________

   Trustee name                             ______________________________________________________________________________

   Address of organisation                  ______________________________________________________________________________

                                            ___________________________________________            Postcode       ______________________

   Postal address of                        ______________________________________________________________________________
   organisation (if same
   as above, write “as above”)              ___________________________________________            Postcode       ______________________

   ABN                                      ___________________________________________

   Telephone numbers                        Work          __________________________________

                                            Fax           __________________________________       Mobile      ________________________

   Website                   ______________________________________                    Email   ____________________________________


   Include this website on the Charities website                     Yes         No
   (www.charities.sa.gov.au) Please tick ( ) one.



Pursuant to Section 6A Collection Licence Agent’s Application                                                                                  1 ı5
Review date: July 2009
                                                                     Application for Licence Pursuant to Section 6A Collection Agent’s Licence


Item 3

1.   Have you had previous experience as a collection agent for a charitable organisation or organisations?
     If “Yes”, please provide the name and address of the charitable organisation/s involved, indicate the nature of the activity (ie. door to door
     collecting, telemarketing, direct mail, etc) and the period of time over which the activity has been carried out.

             No               Yes (please give details on an attachment)


2.   Have you been refused the right or restricted in the right to carry on trade, business or profession for which some form of
     registration, licence or other authority is required by law (whether in this State or elsewhere)?


             No               Yes (please give details on an attachment)


3.   Have you been convicted (in this State or elsewhere) of an offence other than traffic or parking offences?

             No               Yes (please give details on an attachment)



Item 4
What activities will be conducted by the organisation:


     Seeking bequests/sponsorship                                      Badge/Flower/Pin day

     Telemarketing                                                     Internet donations (provide website/s)

     Street/Door to Door collections                                   Other (please specify below)

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________



Item 5
Directors, Office Bearers, Members of the Management Committee, etc. (if insufficient space, please provide details on an attachment
labelled “Directors, Office Bearers etc.”)
 Full name                                   Residential address                                 Position held




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                                                                      Application for Licence Pursuant to Section 6A Collection Agent’s Licence


Item 6

Auditor

Name                      _______________________________________________________________________________________

Business name             _______________________________________________________________________________________

Business address          ________________________________________________________________________________________

                          _________________________________________________                      Postcode _________________________

ABN                       ________________________________________________________________________________________

Telephone numbers              Work     _____________________________________

                               Fax      _______________________________                 Mobile   __________________________________

Section 15(2) of the Collections for Charitable Purposes Act 1939 requires a licensee to have its accounts audited by an approved
auditor as detailed below.


Category of auditor: (Please tick ( ) one)


      Registered Company Auditor (RCA Registration No)           _________________________________

      A member of the Australian Society of Certified Practising Accountants or The Institute of Chartered Accountants in Australia

      A person authorised to audit the accounts of a prescribed association under the Associations Incorporation Act 1985 (provide
      copy of approval)




Item 7
How will the money raised from the activities conducted be distributed to the charities? (e.g. directly credited to bank account,
paid by cheque to the charity etc.)

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________


__________________________________________________________________________________________________________


__________________________________________________________________________________________________________


__________________________________________________________________________________________________________


Item 8
Financial Matters
Date when organisation’s financial year ends                       Day ___________________           Month _______________


Item 9
Bankruptcy Details

Have any persons who are responsible for the financial functions, managerial functions or operation of the bank account for
this organisation ever:
•     been bankrupt
•     been subject to any other forms of insolvency administration

      No
      Yes - Please provide full details. Attach a separate page titled ‘bankruptcy details’.

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                                                                Application for Licence Pursuant to Section 6A Collection Agent’s Licence




Item 10
Supporting documents for a new application: Accompanying this application are:

     A copy of the certificate of incorporation or registration of the organisation

     A copy of the latest audited financial statements (if available)

     A copy of the contract with each charity

     Details of previous fundraising experience

     Any other documents the applicant considers relevant to the application


Supporting documents for a renewal: Accompanying this application are:

     A copy of the latest audited financial statements

     A copy of the signed auditor’s report

     A copy of the fundraising income and expenditure statement

     A copy of the contract with each charity




Declaration

•    I declare that the information contained in this application is true and correct and
•    I acknowledge that under Item of 15C of the Collections for Charitable Purposes Act 1939 it is an offence to make a statement
     that is false or misleading in any information provided under the Act.


Name of applicant              ____________________________________________________________________________________

Office held                    ____________________________________________________________________________________

Signature of applicant         _____________________________________________________                 Date    ______________________




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                                                                Application for Licence Pursuant to Section 6A Collection Agent’s Licence




Checklist for new applications:



     Have you completed and signed the application form.


Have you attached:

     A copy of the certificate of incorporation or registration of the organisation

     A copy of the latest audited financial statements (if available)

     A copy of the contract with each charity

     Details of previous fundraising experience

     Any other documents the applicant considers relevant to the application.


Checklist for renewal applications:


     Have you completed and signed the application form.


Have you attached:

     A copy of the latest audited financial statements

     A copy of the signed auditor’s report

     A copy of the fundraising income and expenditure statement

     A copy of the contract with each.




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