Change Applies to

The change(s) apply to *

Dog/sRatesBuildingBusiness licences and permitsOther

The change(s) is/are *

Postal AddressResidential AddressPhone NumberEmail Address

Describe if Other selected above

Applicant Details

First Name *

Middle Name(s)

Last Name *

Primary Phone *

Secondary Phone

Email address *

Person or Company Details

List the person (people) and/or company the change applies to

Surname or Registered company name *

Full given names (no initials)

Email Address

Phone Number

Postal Address Information

Postal Address

Residential Address Information

Street or lot number

Street Name

Town

Postcode

Property Information

List the properties this change applies to (if applicable)

Street or lot number

Street name or plan number

Town

Property No.

Animal Owners - What is the Street Address of where the animals are kept?

Animal Name

Tag No.

Animal Property AddressAddress where animal is kept

Applicant Declaration

I declare that the above details I have provided are true and correct. Mareeba Shire Council does not take responsibility for the supply of incorrect information. *

Applicant Name *

Date *

Applicant Signature *

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Privacy Notice: Mareeba Shire Council is collecting your personal information in accordance with the Local Government Act 2009 in order to process your application. The information will only be accessed by authorised Council employees. Your information will not be given to any other person or agency unless you have given us permission or we are required by law.

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