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Infection Control Activity Licence Variation Application
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Infection Control Activity Licence Variation Application
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Infection Control Activity Licence Variation Application
For questions relating to your Infection Control Activity Licence:
Please contact the
Health Protection Service
on
02 6205 1700
or email
hps@act.gov.au
.
For technical assistance:
For example errors in the form, issues with attaching files or submitting the form, errors when making a payment etc.
Phone:
13 22 81
For technical assistance with this form please submit a
call back request via the ACT Government Feedback System
or phone the Canberra Connect Contact Centre on
13 22 81
.
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Reference Code:
For questions relating to your Infection Control Activity Licence, please contact the
Health Protection Service
on
02 6205 1700
or email
hps@act.gov.au
.
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Infection Control Activity Licence Variation Application
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Infection Control Activity Licence Variation Application
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Infection Control Activity Licence Variation Application - Submission confirmation
Your submission has been successful. Please keep a copy of this receipt for your records.
Date and time
Reference code
Health Protection Service
ACT Health
Locked Bag 5005
Weston Creek ACT 2611
Phone: (02) 6205 1700
Email: hps@act.gov.au
Current licence details
Infection Control Activity Licence Variation Application
Fields marked with
*
are required
Licence number
*
File number
*
Licence expiry date
*
Proprietor
*
Trading name
*
Variation details
Infection Control Activity Licence Variation Application
Fields marked with
*
are required
Please indicate which variation(s) you are applying for
*
Trading name
New trading name
*
Contact details
Title
Mr
Mrs
Miss
Ms
Dr
Given name
*
Family name
*
Please enter at least one phone number
*
Home phone number
Work phone number
Mobile number
Fax
Email
*
Postal details
New postal address
Address line 1
*
Address line 2
Suburb
*
State
*
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
*
Refurbishment
Were plans showing the structural changes previously submitted?
*
Yes
No
Date plans previously submitted
*
A floor plan showing the layout of all fixtures and fittings of the premises must accompany this application.
Describe the nature of the structural change
*
Has there been a change in the Primary Infection Control Activity?
*
Yes
No
Please select the new Primary Infection Control Activity:
*
Acupuncture
Beauty Therapy
Body Piercing
Colon Hydrotherapist
Dry Needling
Nail Salon
Pathology
Podiatry
Tattoo Studio
Other
Please specify
*
Supporting documents
Infection Control Activity Licence Variation Application
Fields marked with
*
are required
Attach the floor plan showing the layout of all fixtures and fittings of the premises
Download Attachment
Click to upload
File:
Attach a copy of the original licence certificate
Download Attachment
Click to upload
File:
Declaration
Infection Control Activity Licence Variation Application
Fields marked with
*
are required
I confirm that the information supplied on this form is true and accurate and understand the provision of false or misleading information is an offence. I understand that failure to submit all required information and documentation may delay my application and that the provision of false or misleading information may be a criminal offence.
*
Name
*
Position title (Companies)
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