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Submission Acknowledgement

Application for Fish Retailer Licence or Renewal

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Instructions

Application for Fish Retailer Licence or Renewal

Fields marked with * are required

You can use this form to:

Apply for a Fish Retailer Licence or Renew an existing Fish Retailer Licence.

Under the Northern Territory Fisheries Act you will need a Fish Retailer Licence if you are selling fish or aquatic life to the final consumer (eg, Fish and Chip Shop, Market Stall selling a fish dish, Restaurant selling seafood meals)

Fish Retailer Licence is valid for a period of 10 years

How to complete this form

•Select Application Type. •If you are renewing your existing Fish Retailer Licence please enter your licence number (eg B2/1234). •Please select if you are a Company/Partnership or an Individual.•If you are a Company/Partnership you must nominate a natural person to be responsible for the licence.•If you are an Individual you may nominate a natural person to be responsible for the licence.•The trading outlet is the place where the processing and sale of fish is conducted.•The trading outlet nominated person is the person responsible for conducting operations. •Please enter all mandatory fields on this form.

You are not permitted to carry out any activities in relation to this application until you have been advised of the decision.

If you need assistance completing this form, please email FisheriesLicensing@nt.gov.au.

Fields marked with an asterisk (*) must be completed before your form can be processed.

Application Type

Application for Fish Retailer Licence or Renewal

Fields marked with * are required

Application Type *

New licence

Renewal licence

Are you as a... *

Individual

Company / Partnership

Licence Number e.g. B2/1234 *

Individual Details

Application for Fish Retailer Licence or Renewal

Fields marked with * are required

Title

Given Name(s) *

Family Name *

Date of Birth (DD MMM YYYY) *

Day

Month

Year

Gender *

Male

Female

Business Trading Name

Identification

ID Type *

Driver's licence

Passport number

ID Number *

Residential Address

Address Line 1 (e.g. 26 Corning Street) *

Address Line 2

Suburb / Town *

State *

Postcode *

Is the mailing address same as the address above? *

Yes

No

Mailing Address Line 1 (e.g. 26 Corning Street) *

Mailing Address Line 2

Suburb / Town *

State *

Postcode *

Please enter at least one contact number *

Phone (e.g. 0812341234)

Mobile Phone Number (e.g. 0444123456)

Fax Number (e.g. 0812341234)

Email Address (e.g. johnsmith@nt.gov.au) *

Given Name(s)

Family Name

Business Trading Name

Company/Partnership Details

Application for Fish Retailer Licence or Renewal

Fields marked with * are required

ABN (e.g. 12 345 678 910) *

Company/Partnership Name *

Nature of Business *

Business Phone (e.g. 0812341234)

Business Fax (e.g. 0812341234)

Business Address Line 1 (e.g. 26 Corning Street) *

Business Address Line 2

Suburb / Town *

State *

Postcode *

Is the Mailing Address same as the Address above? *

Yes

No

Mailing Address Line 1 (e.g. 26 Corning Street) *

Mailing Address Line 2

Suburb / Town *

State *

Postcode *

Email Address (e.g. johnsmith@nt.gov.au) *

Company/Partnership Name

Nominated Person

Application for Fish Retailer Licence or Renewal

Fields marked with * are required

Would you like to nominate a person other than yourself to be responsible for your license? *

Yes

No

Business

Individual

Substitute

MultipleAddresses

Nominated Person Details

Title

Given Name(s) *

Surname *

Date of Birth (DD MMM YYYY) *

Day

Month

Year

Nominated Person Residential Address

Address Line 1 (e.g. 26 Corning Street) *

Address Line 2

Suburb / Town *

State *

Postcode *

Is the Mailing Address same as the Address above? *

Yes

No

Mailing Address Line 1 (e.g. 26 Corning Street) *

Mailing Address Line 2

Suburb / Town *

State *

Postcode *

Please enter at least one contact number *

Phone (e.g. 0812341234)

Mobile Phone Number (e.g. 0444123456)

Fax Number (e.g. 0812341234)

Email Address (e.g. johnsmith@nt.gov.au) *

Period of Nomination

Date From *

Date To *

Trading Outlets

Application for Fish Retailer Licence or Renewal

Fields marked with * are required

Enter the details of each trading outlet. A maximum of 10 trading outlets may be entered.

Trading Outlet

Name of Outlet *

A current Certificate of Food Business Registration is held for this outlet *

Outlet Street Address

Address Line 1 (e.g. 26 Corning Street) *

Address Line 2

Suburb / Town *

State *

Postcode *

Please enter at least one contact number *

Phone (e.g. 0812341234)

Mobile Phone Number (e.g. 0444123456)

Fax Number (e.g. 0812341234)

Email Address (e.g. johnsmith@nt.gov.au) *

Outlet Nominated Person

Nominated person is the same as the Company Nominated Person

Nominated person is the same as the Individual

Nominated Person is the same person as in the 'Nominated Person' section

Outlet Nominated Person Details

Title

Given Name(s) *

Surname *

Date of Birth (DD MMM YYYY) *

Day

Month

Year

Nominated Person Residential Address

Address Line 1 (e.g. 26 Corning Street) *

Address Line 2

Suburb / Town *

State *

Postcode *

Is the Mailing Address same as the Address above? *

Yes

No

Mailing Address Line 1 (e.g. 26 Corning Street) *

Mailing Address Line 2

Suburb / Town *

State *

Postcode *

Please enter at least one contact number *

Phone (e.g. 0812341234)

Mobile Phone Number (e.g. 0444123456)

Fax Number (e.g. 0812341234)

Email Address (e.g. johnsmith@nt.gov.au) *

Period of Nomination

Date From *

Date To *

Declaration

Application for Fish Retailer Licence or Renewal

Fields marked with * are required

The must sign the form.
• - I declare that the information provided in this application form is true and correct.

I agree *

Individual Name *

Nominated Person Name *

Date *