Preferred Title (Please Delete Inapplicable Titles): Mr Mrs Miss Ms Other

TO:Palmerston North City Council
Private Bag 11-034
Palmerston North 4410
ATTENTION: Team Leader – Governance and SupportNumber of additional sheets attached - ___
IMPORTANT / PLEASE:

• Read ALL instructions carefully
• Print clearly and complete ALL sections in this form (A number of people will read your submission, so please make sure it can be easily photocopied, read and understood).
• Use separate submission forms for different Plan Changes.
• Don’t forget to provide a PHYSICAL ADDRESS, POSTAL ADDRESS and CONTACT PHONE NUMBER.
• Use additional sheets of paper if necessary, indicate above if you are doing so and attach them securely to this form.

Preferred title (please delete inapplicable titles): Mr Mrs Miss Ms Other

Full Name of Submitter:

Plan Change Number and Plan Change Name:

Your Physical Address (for courier purposes):

Postal Address:

Phone (home):

Fax:

Email:

Signature:

Signature of the person making submission or the person authorised to sign on behalf of the person making submission.

(NOTE: A signature is not required if you are making a submission by electronic means.)

1.Gain or affect

1. Could you gain an advantage in trade competition through this submission

/ Please indicate Yes or No
If Yes, go to 1b; If Nogo straight to 2.

1. I am directly affected by an effect of the subject matter of the submission that:

i. adversely effects the environment; and
ii. does not relate to trade competition or the effects of trade competition. / Please indicate
Yes or No
2.The specific provisions of the Plan Change my submission relates to are as follows:
[Specify the specific page number, provision or map number in the Plan Change that your submission relates to:]
3.My submission is that:
[State in summary the nature of your submission. Clearly state whether you support or oppose the specific provisions or wish to have amendments made, give reasons.]
4.I seek the following decision from the Palmerston North City Council:
[Give precise details.]
5.Do you wish to be heard in support of your submission? / Please indicateYes or No
7.If others make a similar submission would you be prepared to consider presenting a joint case with them at any hearing? / Please indicate Yes or No
NOTES TO PERSON MAKING SUBMISSION

1. If you are a person who could gain an advantage in trade competition through your submission, your right to make a submission may be limited by clause 6(4) of the First Schedule of the Resource Management Act 1991.
2. If you are making a submission to the Environmental Protection Authority, you should use form 16B.

This submission should be received by the Palmerston North City Council BY THE CLOSING DATE for submissions to the Plan Change. / PLEASE SEND YOUR SUBMISSION BY:
Mailing to:Palmerston North City Council
Private Bag 11-034, Palmerston North
ATTENTION: Team Leader – Governance and Support
Faxing to:06 355 4115
Delivering to:Council’s Contact Services Centre, Te Manaakitanga o Hineaute, Civic Administration Building, The Square, Palmerston North
Visiting our website: to make a submission
Emailing to:

PRIVACY ACT NOTE: PLEASE NOTE ALL INFORMATION IN YOUR SUBMISSION, INCLUDING YOUR PERSONAL INFORMATION, WILL BE USED TO PROGRESS THE PROCESS OF THIS PLAN CHANGE AND WILL BE MADE PUBLICLY AVAILABLE.