INSPECTION OF HEALTH FOOD PREMISES REQUEST CONSENT FORM

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INSPECTION OF HEALTH FOOD PREMISES REQUEST CONSENT FORM Powered By Docstoc
					                           2009-2010
               DATE PAID:..................................

               RECEIPT NO: ...............................                                   ABN: 42 686 389 537
                                                                                         P O Box 151 Kyneton Vic 3444
               CASHIER INITIALS: .....................
                                                                                Telephone 5422 0333 Facsimile (03) 54 223 623



                                    INSPECTION OF HEALTH / FOOD PREMISES
                                          REQUEST & CONSENT FORM
                                                                              Fee for Inspection is:                               $115.00

                       Requested information cannot be released until written permission is received from the current proprietor.


                 Name of Current Registered Proprietor/s: ..................................................................................................
                                                                                                          ..................................................................................................
                 Postal Address of Registered Proprietor:                                                 ..................................................................................................
                                                                                                          ................................................ Postcode: ........................................
                      Current Registered Proprietor’s Phone:                                              ......................................................................
                    Current Registered Proprietor’s Mobile:                                               ......................................................................
                           Current Registered Proprietor’s Fax:                                           ......................................................................
                     Trading Name of Registered Premises:                                                 ..................................................................................................
                                     Address of Registered Premises:                                      ..................................................................................................
                                                                                                          ..................................................................................................
                 I, being the proprietor of the business at the above address, within the Macedon Ranges Shire Council,
                 hereby consent to the disclosure of any information and the publication of any documents in your
                 possession or power relating to the said premises where the information or the documents have been
                 obtained in connection with the administration of the Food Act 1984 / Health Act 1958 or otherwise to:


                                                                       Name of Applicant:                        ...........................................................................................
                                                                                                    (Person or firm to whom the information or document is to be disclosed to)


                                                         Postal Address of Applicant:                            ...........................................................................................
                                                                                                                 ......................................... Postcode: ........................................


                 Signature of Current Registered Proprietor:                                                     ...........................................................................................

                                                                                               Date:             .......... /………. /……….
                                                              ****The Fee for this application is exempt from GST under Division 81 of the GST Act.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

                                                                    PREMISES INSPECTION REQUEST FEE – $115.00
                                                                                         From 1/7/2009 to 30/6/2010

          CREDIT CARD PAYMENT (BY MAIL/FAX)
          Please charge my credit card for the amount of $                         115.00                               Bankcard                 Mastercard                  Visa Card

          Credit Card No:                                                                                                                                                    Expiry Date: _____/_____


          Name: _________________________________________                                                    Signature: ___________________________________________




                 T:\Health\Forms\2009\Food & Health Registrations\Food & Health Registration Word Docs\2009 Consent Form - Registered Premises-1 July 2009.doc                                 July 13, 2009