Department of Communities, Child Safety and Disability Services
is is an application by a
This form is to beused by a service provider seeking cancellation of its approval as an Approved Service Provider.
Community Services Act 2007 Section 18.
Privacy notice
The Department of Communities, Child Safety and Disability Services is collecting information, including personal information, on this form for the purposes of Section 18 or theCommunity Services Act 2007. This form will be stored in a secure facility and only authorised departmental officers will have access to this information. Where otherwise authorised or required by law, information on this form may be disclosed without your consent.
Section A – All approved service providers must complete section A and sign this declarationDeclaration
Registered Name:
Trading as:
Australian Business Number (ABN):
Street Address:
Contact Person:
Telephone: Facsimile:
Email Address:
Department of Communities, Child Safety and Disability Services
Approved Service Provider number:
does hereby submit an Application under section 18 of the Community Services Act 2007 for cancellation of approval as an Approved Service Provider and declare that all information supplied herein is true at the time of this application.
SignedDate:
Name:Position:
Sign-off should be by the person who has authority to sign on behalf of the corporation.
Section B– This part must be completed by all Approved Service Providers
1. Service Agreement
1.1Is there a current service agreement in force with the Department of Communities, Child Safety and Disability Services? Yes No
1.2Please provide details of the current funding or other assistancereceived
from the Department of Communities, Child Safety and Disability Services.
/ Amount / Details and purpose
Yes
N/A / $pa
- Unspent Funds
and Disability Services?
Yes No. Go to Q.3
Please provide details of the unspent funds received from the Department of Communities, Child Safety
and Disability Services.
/ Amount / Details and purpose
Yes / $pa
- Compliance Issues
that have not been resolved? Yes No
Are there any other compliance issues about which the
Director-General may want to take action? Yes No
Please provide details of the compliance issues.
/ Details of compliance issues
Yes
N/A
Section C – this part is optional.
Please outline the reason why your organisation is seeking cancellation of approved as an approved service provider.
Please ensure that all necessary sections of this form have been completed and all relevant documentation has been attached.
Application for Cancellation of Approval– Form ASP1-3
Version 1December 2012
Page 1 of 4
ACKNOWLEDGEMENT - RECEIPT OF APPLICATION FOR CANCELLATION OF APPROVAL
This acknowledgement will be returned to you to confirm receipt of this application for cancellation of approval as an Approved Service Provider.
Applicant to complete: Name and address:
Department to complete:
The Department of Communities, Child Safety and Disability Services has received your application for cancellation of approval as an Approved Service Provider.
Date of receipt:
For the Department: (signature/ stamp):
Contact officer’s name:
Contact phone number:
Application for Cancellation of Approval– Form ASP1-3
Version 1December 2012
Page 1 of 4