Request to extend currency period

(Section 101 Economic Development Act 2012, version 5.0 effective from 14 December 2015)

BEFORE LODGING YOUR APPLICATION

·  Please check that you have read and completed all sections of this form.

·  Please ensure this application is made before the currency period ends

·  To lodge:

o  Hand deliver one (1) unbound hard copy and one (1) electronic copy to the EDQ Development Assessment Team located at 63 George Street, Brisbane (please note hand deliveries can only be made with a prior appointment with your EDQ Assessment Manager); or

o  Post one (1) unbound hard copy and one (1) electronic copy to the PDA Development Assessment Team at PO Box 15009 City East QLD 4002.

·  For general queries contact the PDA Development Assessment Team at .

Please note that it is mandatory to complete all sections of this form, unless stated otherwise.

1. APPLICANT DETAILS

Individual Name
Company / Organisation / Agency
Contact Name
Postal Address
Telephone Number
Mobile Telephone Number
Email Address

Please provide the following payee details to enable a tax invoice and receipt to be produced:

Individual Name
Company / Organisation / Agency
Contact Name
Postal Address
Telephone Number
Mobile Telephone Number
Email Address
The applicant consents to receiving documents that are required or permitted to be provided under the Economic Development Act 2012 or any other statute, in an electronic format. / Yes
No

2. APPROVAL HISTORY

Priority Development Area (PDA)
Address
PDA Reference Number
Date of Decision

3. CURRENCY PERIOD

Currency period stated on the approval / years from the date of decision
Date original currency period to lapse
Proposed date of extension to currency period

4. ATTACHMENTS

To support the application please attach plans, drawings, and/or reports:

To support the application please attach plans, drawings, and/or reports:
Description / Date

5. PRIVACY STATEMENT

Information collected is also subject to the Right to Information Act 2009 and the Information Privacy Act 2009.The information provided may be publicly released and or provided to third parties and other government agencies—but only for the purposes for which the information is being collected.The proponent's personal information will be stored on departmental files and may be disclosed for purposes relating to the processing and assessment of the application or as authorised or required by law.

6. APPLICANT’S DECLARATION AND ACKNOWLEDGEMENT

The applicant warrants that the information provided to the EDQ Development Assessment Team in relation to this extension to currency period application is true and correct, and acknowledges that if any information is knowingly false, the applicant may be exposed to penalties under section 165 of the Economic Development Act 2012.

By making this application, I declare that all information in this application is true and correct to the best of my knowledge.

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Signature of Applicant/Authorised Person Print Name and Position

______

Date