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Application for Renewal of a Tobacco Retail Licence
Tobacco Control ActPlease print in block letters. If there is insufficient space, attach extra sheets. All applicable questions must be answered and full particulars provided.
Application for Renewal of a Tobacco Retail Licence1. Application detailsThis licence is held by a:
Natural person (Sections 2a, 3, 4, 5, 6 and 8 of application)
Natural persons in partnership (Sections 2b, 3, 4, 5, 6 and 8 of application)
Corporation (Sections 2c, 3, 4, 5, 6, and 8 of application)
Association (Sections 2d, 3, 4, 5, 6 and 8 of application)
Current Licence Number
Expiry date
2a. Applicant details – Natural PersonTitle Mr Mrs Ms Miss
Surname
Given name
Residential / business address
Postal address(all correspondence will be mailed to this address)
Telephone Mobile
2b. Applicant details – PartnershipFull name of each partner (if space is insufficient, please provide information as an attachment)
1. Title Mr Mrs Ms Miss
Surname
Given name
2. Title Mr Mrs Ms Miss
Surname
Given name
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Application for Renewal of a Tobacco Retail Licence
3. Title Mr Mrs Ms Miss
Surname
Given name
4. Title Mr Mrs Ms Miss
Surname
Given name
Business address
Postal address(all correspondence will be mailed to this address)
Telephone Mobile
2c. Applicant details - CorporationCorporation name
ACN
Registered Office address
Postal address(all correspondence will be mailed to this address)
Telephone Mobile
2d. Applicant details - AssociationAssociation name
Association number
Public Officer
Business address
Postal address(all correspondence will be mailed to this address)
Telephone Mobile
3. Business detailsHave there been any changes to your business details Yes No
If no, go the section 4
If yes, please continue with this section
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Application for Renewal of a Tobacco Retail Licence
Do you hold a current licence under the Liquor Act? Yes No
If Yes, please provide the liquor licence number
Type of Tobacco Retailer
Fixed premises Mobile premises Specialist tobacconist
Business name
Business number
Nature of business (eg supermarket, petrol station, smoko-van etc.)
Physical location address or location of mobile premises when not in use
Telephone Mobile
4. Manager’s detailsIf the applicant is the holder of a liquor licence the nominee of that licence must be the manager on this licence.
Title Mr Mrs Ms Miss
Surname
Given name(s)
Other names (including maiden name and alias/es)
Date of birth (must be over 18 years)
Place of birth
Contact address
Telephone Mobile
Manager’s Signature Date
5. Supporting documentsThe following documents are required to be lodged with the application.
Current photographic identification of manager
Continuing manager must complete a statutory declaration (format attached to this form), stating that they have not been convicted of any offences since the last criminal history report was provided and whether they are the subject of any pending charges for an offence.
New manager must provide evidence of lodgement of Criminal History Name Check Application for the proposed manager only. Please note that applications will not be processed until receipt of the Criminal History Report which may take around 6 weeks to process by SAFE NT.
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Application for Renewal of a Tobacco Retail Licence
6. Unattested Declaration under the Oaths, Affidavits and Declarations ActI (insert name)
Of(insert address)
Postcode
solemnly and sincerely declare that:1. all statements and information contained in this application are true and correct to the
best of my knowledge;2. I have read and understood the information contained in this application;
and I further state that:3. this declaration is true and correct; and4. I know that it is an offence to make a declaration that is false in any material particular.
This declaration is made at(Place)
On(Date)
Signature of Applicant
Note: A person wilfully making a false statement in a statutory declaration is guilty of a crime and is liable to a penalty or imprisonment, or both.
7. Privacy StatementThe Department of Business complies with the Information Privacy Principles scheduled to the Information Act.
8. Payment optionsContact your local Territory Business Centre for the relevant schedule of fees.
Cash - Territory Business Centre
Cheque - payable to RTM (Receiver to Territory Money)Credit card Visa MasterCard
Credit Card number
Expiry
Name on card
I hereby authorise the Territory Business Centre to debit the above credit card for the amount of $
Amount in words dollars
Signature of cardholder Date
Contact phone number
9. Lodgement optionsApplications to be lodged at a Territory Business Centre with the prescribed fee.
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Application for Renewal of a Tobacco Retail Licence
DarwinGround Floor, Development House76 The EsplanadeDarwinGPO Box 9800Darwin NT 0801t (08) 8982 1700f (08) 8982 1725Toll free 1800 193 111e [email protected]
KatherineShop 1, Randazzo Building18 Katherine TerraceKatherinePO Box 9800Katherine NT 0851t (08) 8973 8180f (08) 8973 8188e [email protected]
Tennant CreekShop 2, Barkley HouseCnr Davidson and Paterson StreetTennant CreekPO Box 9800Tennant Creek NT 0861t (08) 8962 4411f (08) 8982 1725e [email protected]
Alice SpringsGround Floor, The Green Well Building50 Bath StreetAlice SpringsPO Box 9800Alice Springs NT 0871t (08) 8951 8524f (08) 8951 8533e [email protected]
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Application for Renewal of a Tobacco Retail Licence
Northern Territory of Australia
Statutory Declaration
(1)Insert full name and address of person making declaration
(2)Here insert the matter declared to, either directly following the word ‘declare’ or, if the matter is lengthy, insert the words ‘äs follows’ and thereafter set out the matter in numbered paragraphs
(3)Signature of the person making the declaration(4)Signature of the person before whom the declaration is made
(5)Here insert full name of person before whom the declaration is made, legibly written, typed or stamped
(6)Here insert contact address or telephone number of person before whom the declaration is made
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Application for Renewal of a Tobacco Retail Licence
I, (1)
Of
solemnly and sincerely declare (2)
That I have not been charged, summonsed or convicted of any offence since my last criminal history check for my tobacco licence and I am not the subject of any pending charges for any offence.
This declaration is true and I know it is an offence to make a statutory declaration knowing it is false in a material particular.
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Application for Renewal of a Tobacco Retail Licence
Declared at
the day of 20
(3)
Witnessed by
(4)
(5)
(6)
Note: This declaration may be witnessed by any person who is at least 18 (eighteen) years of age.
Note: This written statutory declaration must comply with Part 4 of the Oaths Affidavits and Declarations Act.
Note: Making a declaration knowing it is false in a material particular is an offence for which you may be fined or imprisoned.
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