Children’sServicesAct1996,Children’sServicesRegulations2009
Aboutthisapplication
•TheSecretaryorDelegateoftheDepartmentofEducationandEarlyChildhoodDevelopmentmaycancelalicenceorserviceapprovaltotheextentthatitrelatestoanapprovedassociatedchildren’sservice,uponrequestbyalicenseeorapprovedprovider,orifalicenseeorapprovedproviderhasceasedoperatingachildren’sservice.
•Alicenseeorapprovedprovidershouldusethisform whenrequestingtocancelalicenceorserviceapproval.
Applicant/Licensee/ApprovedProviderdetails
1.Children’sservicelicencenumberorserviceapprovalnumber
2.Fullnameoflicenseeorapprovedprovider
3.PostaladdressoflicenseeorapprovedproviderBuildingname(ifapplicable)
Unit,floor,streetnumberandstreetname orPOboxSuburb/TownStatePostcode
Children’sservicedetails
4.Nameofchildren’sservice
5.Addressofchildren’sservice(P.O.boxescannotbeaccepted)
Unit,floor,street numberandstreetnameSuburb/TownStatePostcode
VIC
6.Postaladdressofchildren’sservice
Sameas postal addressinquestion 3Sameasaddressinquestion5
OrdifferentpostaladdressspecifiedbelowBuildingname(ifapplicable)
Unit,floor,streetnumberandstreetname orPOboxSuburb/TownStatePostcode
7.EmailaddressDaytime telephone numberFaxnumber
8.InwhichLocalGovernmentAreaistheservicelocated?(egPortPhillip,SwanHill)
PrivacyTheSecretarytotheDepartmentofEducationandTraining iscommittedtoresponsibleandfairhandlingofpersonalinformation,consistentwiththe InformationPrivacyAct2001 (Vic),the HealthRecordsAct2001 (Vic)and otherstatutoryobligationsincludingobligationsundertheChildren’sServicesAct1996(Vic).TheDepartmentofEducationandTraining mayneedtodiscloseyourpersonalinformationtootherStateandCommonwealthagenciestocheckorconfirmtheinformationyouhaveprovided.Youcanrequestaccesstoorupdateyourpersonalinformationbycontactingus.Ourinformationprivacypolicyisavailableat
CS19
Version (01/11/11)
Cancellationdetails
9.Onwhatdatedoyouproposethecancellationofthelicenceorserviceapprovaltocomeintoeffect?
10.Whyareyourequestingthecancellationofthelicenceorserviceapproval?Pleaseprovideanyevidencesupportingthosereasons.
11.Howdoyouintendtonotifytheparentsorguardiansofchildren whoarecaredfororeducatedbytheserviceaboutthecancellationofthelicenceorserviceapproval?Describetheprocessyouproposetoundertake.
Contactpersonforapplication
12.Providedetailsofthepersonwhowillbethecontactforanyenquiriesaboutthisapplication.
Title (Mr,Mrs,etc)Family NameGivennames
EmailaddressBusiness hourstelephonenumberFaxnumber
Postaladdress
Sameaslicensee’sorapprovedprovider’spostaladdressinquestion3
Sameaschildren’sservicepremisesaddressinquestion5
Sameaschildren’sservicepostaladdressinquestion6
OrdifferentpostaladdressspecifiedbelowBuildingname(ifapplicable)
Unit,floor,streetnumberandstreetname orPOboxSuburb/TownStatePostcode
Declarationandsignature
13.Ideclarethat:
•theinformationinthisapplicationandanyattachmentsaretrueandcorrect;
•ifabodycorporate,thisapplicationissignedinaccordancewiththerulesgoverningthebodycorporatelegalentity.
Whomustsign:
Individuals:Theindividualapplicant.
Company:Twodirectorsofthecompany,oradirectorandcompanysecretary,orifsoleproprietorthesoledirector.Incorporatedassociation:ThePublicOfficerandoneothermemberofthemanagementcommittee.
Cooperative:Twodirectorsofthecooperative,oradirectorandoneotherofficerofthecooperative.
Partnership:Amanagingpartnerwhoisauthorisedtosignonbehalfofthepartnership.Thissignaturebindsallpartners.Corporation/GovernmentSchoolCouncil:Signedinaccordancewithrulesofthecorporation/council.
SignaturePrintednamePosition (if bodycorporate)Date
X
SignaturePrintednamePosition (if bodycorporate)Date
X
Documentchecklist
Ifavailable,youshouldattachevidencesupportingyourreasonsforthecancellation.
Whattodonext
Thereisnofeetolodgetheapplication.Lodgeyourapplication
Byposting to:.DepartmentofEducationandTraining
QualityAssessmentandRegulationDivisionServiceAdministrationandSupportUnit
GPOBox4367MelbourneVictoria3001
Whathappensthen
•Youwillreceiveanacknowledgementthatyourapplicationhasbeenreceived.Youmayneedtoprovidefurtherinformation.
•Ifthe Secretarydecidestocancelyourlicenceorserviceapproval,youwillbegivenwrittennoticeofthecancellationatleast7daysbeforethecancellationtakeseffect.
•Ifanychangeoccursintheinformationyouhaveprovidedinyourapplication,youmustnotifytheDepartmentofEducationandTrainingassoonaspossible.