Compliance Assessment Form

(Version 1.0 effective 14 December 2015)

BEFORE SUBMITTING FOR COMPLIANCE ASSESSMENT

  • Please check that you have read and completed all sections of this form.
  • To lodge:
  • Hand deliverone (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 PDA Assessment Manager); or
  • Postone (1) unbound hard copy and one (1) electronic copy to the EDQ Development Assessment Team at PO Box 15009 City East QLD 4002.
  • For general queries contact the EDQ Development Assessment Team .

1. APPLICANT DETAILS

The applicant is responsible for ensuring the accuracy of the information provided because any endorsement issued will be issued to the applicant.

Individual Name
Company / Organisation
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
ABN
Postal Address
Telephone Number
Mobile Telephone Number
Email Address

2. COMPLIANCE ASSESSMENT

Please provide details regarding the relevant compliance assessment requirements.

Priority Development Area
PDA Development Approval Reference Number
DEV20/
Identify the condition/s of the PDA development approval or the clause of an infrastructure agreement to which the compliance assessment requirements relate to.
Condition Number / Description

3. ATTACHMENTS

To support the compliance assessment please attach plans/supporting information.

Description / Date

4. 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.

5. APPLICANT’S DECLARATION

The applicant warrants that the information provided to the EDQ Development Assessment Team in relation to this compliance assessment is true and correct, and acknowledges that if any information is knowingly false, the applicant may be exposed to criminal 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 PersonPrint Name and Position

______

Date