ingham showgrounds hire application...cs 297/2 – 06/2020 page 1 of 14 ingham showgrounds hire...

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INGHAM SHOWGROUNDS HIRE APPLICATION

FORM

The Ingham Showgrounds Hire Application form is used to book all events to be held at the Ingham Showgrounds.

To return your completed form or for further information, please contact Council’s Facility Coordinator via email, [email protected], phone (07) 4776 4715, in person at Council’s Main Office, 25 Lannercost Street, INGHAM QLD, or via post PO Box 366, INGHAM QLD 4850.

SECTION 1 – APPLICANT DETAILS Name of person or Organisation

Primary Contact Person

Postal Address

Phone Mobile Number

Email

SECTION 2 – HIRE DETAILS

Period of Hire From: To:

Event Date/s

Time/s From: To:

Name of Event

SECTION 3 – SECURITY BONDS

Bonds Please tick applicable

☐ Bond for Pavilion and Multi-purpose Sports Arena……………………………………$500 ☐ Bond for minor events…………………………………………………………………….………$500 ☐ Bond for major events…………………………………………………………………….…….$2000 ☐ Bond for seasonal use……………………………………………………………….…………...$500

An EFT Bond Refund form (Annexure B) is required to be filled out and returned at time of booking to ensure the security bond is refunded in a timely manner.

SECTION 4 – FACILITIES TO HIRE

Eastern Side of Ingham Showgrounds Please tick applicable

☐ *Oval 1 (No lighting)……………….....$93.00 Per day or part thereof

☐ Oval 1 Lighting – 50%.................…$15.50 Per hour

☐ Oval 1 Lighting – 75%....................$24.50 Per hour

☐ Oval 1 Lighting – 100%………………$32.00 Per hour

☐ Multi-purpose Sports Arena…………$93.00 plus electricity Per day or part thereof

☐ All Inclusive Use of Eastern Side…$225.00 plus electricity (Includes Oval 1, Multi-Purpose Sports Arena and Groundhire) Per day or part thereof

☐ Ground Hire…………….………………….$51.00 (Grounds outside Oval 1 and Multi-Purpose Arena) Per hour

☐ Seasonal Use of Showgrounds..…$615.50 (Including use of dressing sheds – Sporting Clubs) Per season

☐ Club Room…………………………...….$8.00 Per room per day or part thereof

☐ Canteen…….……….……………..……$56.00 Per day or part thereof

☐ Horse or Cattle Stalls………….…...$35.00 (with an associated event only) Per day or part thereof

☐ Camping………………………………….$45.00 (with an associated event only) Per day or part thereof

☐ Traveller Camping………………..…..$15.00 (with working animals only) Per night or part thereof

☐ Shoulder Period Fee……………..….$16.00 (Access to Showgrounds on the days prior and post the major event) Per day

☐ Auction Sale………………………………$4.50 (Not part of any major event) Per head

mailto:[email protected]

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FORM

OFFICE USE ONLY

Booking Fee Invoice: Amount:

Bond Invoice: Amount:

Hire Fee Invoice: Amount:

Confirmation Letter Sent: ☐ Yes ☐ No

Induction Booked:

Invoices Paid: ☐ Yes ☐ No

After Use Check

Bond to be Refunded?

☐ Yes ☐ No

If no, please explain why?

……………………………………………………………………………………….........................................................................

………………………………………………………………………………........................................................................….…....

Western Side of Ingham Showgrounds Please tick applicable

☐ *Pavillion……………………………………………………………………………………..…...$167.00 (Includes kitchen and mezzanine floor) Per day or part thereof

☐ Pavillion.........................................................................................................…$23.00Per hour (Up to 3 hours)

☐ Mezzanine Floor.................................................................................................$5.00 Per hour

☐ All Inclusive Use of Western Side of Ingham Showgrounds…………….………$225.00 plus electricity (Pavillion, Storage Shed, Ground Hire) Per hour

☐ Pavillion Shed……………………………………………………………………………………... $55.00 Per day

☐ Pavillion Shed………………………………………………………………………………………….$5.00 Per hour

☐ Hire for Range of Hours 13-40 hours per week………………………………..………$35.00 Per week

*Items marked with an asterisk attract a 50% booking fee as set out in the Conditions ofHire (Annexure A – Clause 4)

SECTION 5 – LICENSED FUNCTIONS (IF APPLICABLE)

To be completed by an Ingham Police Officer

Hinchinbrook Shire Council:

To Whom it May Concern,

I hereby certify that …………………………………………………………………………………………

Club/Association/Organisation has advised the Ingham Police Service of this licensed

function.

………………………………………………………………………………………. Officer in Charge, Ingham Police

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FORM

Privacy Notice and Disclaimer

Hinchinbrook Shire Council is collecting your personal information to process your submission in Shire Hall bookings as stated in this form. The collection of this information is authorised under the Local Government Act 2009. Your personal information will not be disclosed to a third party unless required by law. You may access this information on the appropriate form obtainable from Council's website at any time.

Signature: ……………………………………………………………………………………..……… Date: …………………..……………………………………

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FORM ANNEXURE ‘A’

CONDITIONS OF HIRE

The Hinchinbrook Shire Council (Council) is the Trustee or registered owner of the facility and has granted hire of the facility subject to the following conditions:

1. APPLICATION The right to the use the facility is subject to the Council receiving an application in the required form signed by the proposed hirer undertaking to comply with these conditions. If the proposed hirer is a club the application must include the personal undertaking by the president and secretary of the club.

2. RESERVATION Reservations must be made in advance and should include all days the facility is required, including set up and clean up days. An example is: if a facility is to be hired for a Saturday evening and you require Friday to set up and Sunday to clean up, your application will need to be for three (3) days (Friday, Saturday and Sunday).

3. SECURITY BOND A security bond in accordance with the Council’s fees and charges schedule shall be paid by the hirer prior to using the facility as a guarantee of fulfilment of these conditions, and as security against damage to the building or any fittings and furniture contained therein, and for any cleaning arranged by the Council resulting from the hirer’s use of the premises.

The hirer shall be liable on demand by the Council to pay any further amount in excess of such bond to meet the full cost of such damage and cleaning. If there is no breach of the conditions of usage or damage to the building or any fittings and furniture therein or abnormal cleaning the security bond will be returned within two (2) weeks of the use of the premises.

An Electronic Funds Transfer form (Annexure E) is required to be filled out and returned at the time of booking to ensure the security bond is refunded in a timely manner.

If the Security Bond is retained, at the request of the hirer for subsequent hires, it is a requirement that the amount of the security deposit is in line with Council’s current Schedule of Fees and Charges prior to collecting the keys.

4. BOOKING FEES Items marked with an asterisk * on the application to hire form attract a 50% booking fee. This fee is non-refundable, except where an event has been cancelled due to inclement weather. If the facility is utilised, the booking fee will be put towards the total rental charge payable.

Council will issue an invoice to cover the applicable booking fees within seven (7) days of receipt of a completed application to hire form. Once this invoice has been paid, your booking will be confirmed in writing. Council will issue an invoice for the remaining hire fees one (1) month, if possible, prior to the booking date and must be paid in full before use of the facility will be permitted.

Booking fees are 50% of the total rental charge payable and apply to the following facilities within the Ingham Showgrounds:

Eastern Side of Ingham Showgrounds Western Side of Ingham Showgrounds

Oval 1 Pavilion (incl. kitchen and mezzanine floor)

Multi-purpose Sports Arena Storage Shed

Ground Hire Exclusive Use of Eastern Side of Showgrounds

Canteen

Exclusive Use of Eastern Side of Showgrounds

5. HIRE FEES Hire Fees shall be in accordance with the Schedule of Fees and Charges as adopted by Council and shall be payable prior to the date of the function. The current Schedule of Fees and Charges can be found on Council’s website at https://www.hinchinbrook.qld.gov.au/our-council/rates-fees-and-charges/.

Daily hire rates apply to days on which the primary event/competition is held and include a day or any part of a day unless otherwise specified as an hourly rate of hire in the Schedule of Fees and Charges.

https://www.hinchinbrook.qld.gov.au/our-council/rates-fees-and-charges/

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FORM No hire charge is applicable for a day either side of the primary event/competition and which are required for setting up or pulling down the event. Additional set up or pull down days will be charged at the ‘Shoulder Period’ rate as per the current Schedule of Fees and Charges.

Daily hire charges are expressed at GST inclusive.

6. CANCELLATION OF BOOKING Any cancellation of a booking for the hire of the facility shall be made at least 24 hours prior to the date of the function.

All fees associated with the booking of a facility will be refunded excluding the booking fee as mentioned in Clause 4. If a cancellation is due to inclement weather the hirer is eligible for the booking fee to be refunded or transferred to a new booking date.

7. PAYMENT OF ACCOUNT An invoice will be sent out 1 month, if possible, prior to the booking date and must be paid in full before use of the facilities will be permitted.

Note: Prices quoted are for the current financial year and are subject to an annual increase.

8. EMERGENCY CALL OUTS Emergency (only) call outs during event should be directed to: Council’s Community Services Facilities Officer Mr Russell Andrews Mobile: 0408 455 726.

Please note, non-emergency call outs may be deducted from your bond.

9. CAMPING AREA (a) Camping within the grounds is permitted with an associated event only within the areas specified in the map (Annexure

B) (b) Changes to the approval of the use of the camping area may occur in the event of inclement weather or other

unforeseen circumstances. The cleanliness of the camping area is the responsibility of the hirer as per any other part of the facility nominated on the hire application.

10. DEFINITION OF A MAJOR EVENT A major event is considered to meet one or more of the following criteria:

• extensive camping area; • event held over two (2) days or more; • held over both sides of the grounds; • expected patronage over 500; • requires heavy vehicles within the grounds; or • a circus.

11. USE OF FACILITY AFTER ENGAGED TIME If the area is not vacated by the nominated time, the hirer shall forfeit the entire bond and pay the fee that would otherwise apply for use of the Facility.

12. NOISE Conduct event in accordance with Workplace Health and Safety requirements and local laws; stating that music must be turned down at 10:00pm and the facility vacated by 12:00am. Every consideration must be given by people using and vacating the area to the residents who live nearby regarding minimising noise and unruly behaviour.

13. INDUCTIONS AND INSPECTIONS An induction and post-event inspection of the facility is required and it is preferable that such inspections are undertaken jointly with Council Officers and representatives of your Association. Contact should be made with Council Officers to organise a date and time for an induction which should take place no later than ten (10) days prior to your event.

Please note that persons performing the induction must be present at the event until the end of hire. Charges may apply should the induction not be attended at the scheduled time without advance notice.

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FORM 14. INSURANCE

The hirer shall take out and keep current during the entire period of hire, a public liability insurance policy in a form approved by the Council, in the joint names of the Council and the hirer, insuring, for a sum of not less than $20,000,000.00 ($20Million), the Council and the hirer against all actions, costs, claims, charges, expenses and damages whatsoever which may be brought or made or claimed against the Council or the hirer or both arising out of or in relation to the hiring arrangement.

The policy must also confirm that the insurance cover include the indemnity required to be given by the hirer as part of this agreement. Proof of this policy must be by way of Certificate of Currency which must be annexed to this agreement, and form part of the agreement.

15. INDEMNITY The hirer agrees to indemnify, and keep indemnified, and to hold harmless the Council, its servants and agents, and each of them from and against all actions, costs, charges, expenses and damages whatsoever which may be brought, or made, or claimed against them, or any of them, arising out of, or in relation to the hiring engagement.

16. ACTS AND REGULATIONS The hirer shall conform to the requirements of the Health Act, Local Government Act, any Local Law or Regulation made thereunder, and shall be liable for any breach of such Acts, Local Law or Regulation. All other statutory rules, provisions and regulations of the Commonwealth of Australia or State of Queensland for the time being in force must be complied with by the user and the notices given to the proper offices.

17. PERMISSION TO OCCUPY (a) The hirer shall only be entitled to the use of the particular part or parts of the facility hired on the date set out in the

Schedule to the application and the Council reserves the right to permit any other portion of the facility to be hired for any other purpose at the same time.

(b) The right conferred on the hirer shall be a permission to occupy and shall not be construed as a tenancy. Nothing contained in these conditions shall confer on a regular hirer the right to exclusive possession and the Council may at its discretion allow other individuals and groups to have casual use of the premises.

18. ASSIGNMENT Hirers that are granted permission to use the facility shall not assign the right of use to any person, organisation or body.

19. ADULT SUPERVISION Hirers under the age of 18 years must have the application form referred to in Clause 1 completed by an adult who will be supervising the function. The person completing the application form and whose signature appears on the same is subject to these terms and conditions.

20. GAMBLING No game of chance, at which either directly or indirectly money is passed as a prize, shall take place in any part of the premises, with the exception that this clause shall not prevent the hirer using the premises for games of Bingo or equivalent, providing relevant permits have been obtained.

21. DETERMINATION If the hirer commits, permits or allows any breach or default in the performance and observance of any of these conditions the Council may terminate the permission to use the premises and the hirer shall immediately vacate the premises and the security deposit shall be forfeited to the Council.

22. THEFT Neither the Council nor its servants shall be liable for any loss or damage sustained by the hirer or any person, firm or corporation entrusting to or supplying any article or thing to the hirer by reason of any such article or thing being lost, damaged or stolen. The hirer hereby indemnifies the Council against any claim by any such person, firm or corporation in respect of such article or thing.

23. CORPORATE MANAGER Wherever appearing in these conditions and where the context so admits the expression (nominated Council officer) shall be deemed to include any other officer of the Council acting with the authority of the (nominated Council officer) expressly or implied.

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FORM 24. REFUSAL TO GRANT HIRE

It shall be at the discretion of the Council to refuse to grant the hire of the complex in any case and, notwithstanding that permission to hire the premises may have been granted or that these conditions may have been accepted and signed and the fees and deposit paid, the Council shall have the power to cancel such permission and direct the return of the fees and deposits so paid. The hirer hereby agrees in such case to accept the same and shall be held to have consented to such cancellation and to have no claim at law or in equity for any loss or damage in consequence thereof.

25. GOOD ORDER (a) The hirer shall be responsible for the full observance of these conditions and for the maintenance and preservation of

good order in and about the facility throughout the whole duration of the period of use. (b) No spitting, obscene or insulting language or disorderly behaviour or damage to property shall be permitted in any part

of the facility. (c) It is the responsibility of the hirer to ensure that appropriate onsite security services are engaged for the whole duration

of the event. (d) The hirer is responsible for damages that patrons may cause in and around the facility.

26. GROUND PREPARATION Responsibility for ground preparation to a condition safe and suitable for the conduct of your activities rests with the hirer of the venue. Arrangements in that regard should be made at an early stage.

27. SET UP Any changes to the ground, floor surface, grandstands (curly bells) or any other part of the facility may be arranged at the hirer’s expense. Upon completion of the hire, the ground, floor surface, grandstands (curly bells) and any other changes must be restored to their original condition by the hirer concerned or Council will carry out necessary works and charge the hirer.

28. CLEANING So as there is no dispute concerning the requirement to clean, hirers are expected to leave the premises in the same condition as upon their arrival, this includes removal of all manure from the covered arena floor, oval, cattle and horse stalls and camp grounds.

29. CLEANLINESS The hirer is responsible for leaving the premises in a clean and tidy state, and shall immediately remove all rubbish, refuse and waste matter. Twenty (20) refuse bins are included with the hire of the facility which must be lined up in the designated location identified during the facility induction for disposal the following week.

Council has an additional forty (40) community wheelie bins for hire during the event, however, these are subject to availability and have a bond charge payable.

The hirer will need to organise for supply of additional bins through a private contractor, if these are required.

30. STOCK Stock required for an event/competition shall be allowed to be kept on the premises for a maximum period of one (1) day before and one (1) day after the day/s of such event/competition and no further.

31. NATIONAL LIVESTOCK IDENTIFICATION SYSTEM (NLIS) All cattle, sheep, goats, pigs, bison, buffalo, alpacas, llamas or designated animal prescribed under a regulation as a special designated animal entering this facility must:

(a) be fitted with an approved NLIS device; (b) be scanned upon arrival and before entry onto the facility proper. The movement to and from the facility must be uploaded and transferred to the NLIS database within forty-eight (48) hours of movement and a transaction report/receipt from the NLIS database provided to Council within forty-eight (48) hours of receipt.

In the event that Council does not receive the transaction report/receipt, Council is obliged to notify the Department of Agriculture & Fisheries of possible breaches of NLIS legislation. Stringent penalties apply to such breaches.

32. HORSE HEALTH DECLARATION & MOVEMENT RECORDS A Horse Health Declaration (Annexure C) is required for every horse that enters the facility; this can also be used as a movement record. Organisers of horse events must keep records of each horse that has attended their event and provide copies to Council within forty-eight (48) hours of the event. A movement record must capture the following details:

• Date of the event

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FORM • Name and address of the person who kept the animals before the event and of the person keeping the animal after the

event • Where the animal/s came from • When the animal/s arrived and left the event • Description of animal/s

The details specified above must be recorded, as well as when the horses arrived at the show and when they left.

These records can be kept in any format and must be provided to Council within forty-eight (48) hours of the event and must be kept for two (2) years.

33. PROPERTY IDENTIFICATION CODE (PIC) Council’s Property Identification Code (PIC) is QIHC0260 and should be referenced on all movement records.

34. DAMAGES (a) The floors, walls or any other part of any building or structure or any fittings or furniture in on or about the facility shall

not be broken, pierced by nails or screws or in any other way damaged. (b) The hirer shall accept full financial responsibility for damage to Council property except for normal wear and tear.

35. SIGNAGE No notice, sign, advertisement, scenery, fittings or decorations of any kind shall be erected on any building or other structure or attached or affixed to the walls, doors or any other portion of any building, fittings or furniture, without prior consent of Council.

36. SMOKING Smoking is not permitted in any Council building or within five (5) metres of the entrances.

37. LIQUOR The sale of liquor on the premises is forbidden unless the hirer obtains a permit from the appropriate authority, and the permit is produced to the Council who shall make an endorsement on the Schedule to the application.

Please refer to: https://www.business.qld.gov.au/industries/hospitality-tourism-sport/liquor-gaming/liquor/licensing/applications

Please note: that a licence is not required for a private function where liquor is not being sold e.g. birthday party or wedding etc.

38. NO GLASS The hirer will ensure that no glass or glass receptacles will be used at the Facility on the date required.

39. FREE ACCESS Any nominated Council officer Council may appoint, shall at all times be entitled to free access to any and every part of the complex.

40. DISPUTES In the event of any dispute or difference arising as to the interpretation of these conditions, or of any matter or thing contained therein the decision of the Council thereon shall be final and conclusive.

41. PERFORMING RIGHTS In the case of dramatic or other performance or concert, the hirer shall not produce, or permit to be produced or performed, any dramatic or musical work in infringement of the copyright or performing right of any owner of such right or rights, and the hirer agrees to indemnify Council against any claim for breach or copyright or any other action herewith.

42. POLICE The hirer shall, when so directed by Council, arrange for police attendance.

43. AIRCRAFT The use of aircraft to and from the showgrounds is prohibited unless such activities are approved in writing by Council.

https://www.business.qld.gov.au/industries/hospitality-tourism-sport/liquor-gaming/liquor/licensing/applications

https://www.business.qld.gov.au/industries/hospitality-tourism-sport/liquor-gaming/liquor/licensing/applications

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FORM 44. LEGISLATION COMPLIANCE

Fire and Emergency Services Act 1990

Building Fire Safety Regulations 2008

Areas around fire escape doorways and walkways are to be kept clear at all times. Fire Escape Plans are not to be removed from the walls or covered over.

Hirers need to comply with Fire Safety Regulations. If you are unsure of the procedure, the Queensland Fire and Emergency Services can inspect the facility to ensure that regulations are being met.

Hinchinbrook Shire Council may conduct spot checks during events for compliance of requirements for this section. If an event is found to have not met these requirements an induction will be conducted immediately, the costs for this will be deducted from the bond.

To maintain fire safety standards the maximum number of persons permitted in the Pavilion is 625 (inclusive of bar and catering staff).

FOOD ACT 2006—FOOD REGULATIONS 2006

It is the Hirer’s responsibility to comply with all legislative requirements including the Food Safety Standards. If a food licence is required and you are not a current licensee, a food business licence must be applied for at least ten (10) days prior to the event.

Please refer to: www.health.qld.gov.au/public-health/industry-environment/food-safety/regulation/act-standards

http://www.health.qld.gov.au/public-health/industry-environment/food-safety/regulation/act-standards

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FORM ANNEXURE ‘B’

CAMPING GROUNDS

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FORM ANNEXURE ‘C’

HORSE HEALTH DECLARATION

SECTION 1 – EVENT DETAILS

Event Title

Event Date

SECTION 2 – OWNER/PERSON IN CHARGE OF HORSE/S

Full Name

Company

Residential Address

Postal Address ☐ As above

Telephone Mobile

Email

SECTION 3 – PROPERTY OF ORIGIN OF HORSES

Full Address Including property name

QDPI PIC Number

Waybill/Movement Document Movement

SECTION 4 – HORSE DETAILS

Registered Name Description/Sex Brand/Microchip Breed

Conditions Prior to Entry

1. All horses will be shampooed, rinsed and allowed to dry, and their hooves will be picked clean of all solid materials and washed with shampoo; and

2. All vehicles and equipment accompanying the horses will be cleaned to remove all solid materials that can contain disease agents and then disinfected.

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FORM

Privacy Notice and Disclaimer

Hinchinbrook Shire Council is collecting your personal information to process your submission in Shire Hall bookings as stated in this form. The collection of this information is authorised under the Local Government Act 2009. Your personal information will not be disclosed to a third party unless required by law. You may access this information on the appropriate form obtainable from Council's website at any time.

Signature: ……………………………………………………………………………………..……… Date: …………………..……………………………………

SECTION 5 – DECLARATION

I declare that:

1. The horses named in this Declaration are in good health, eating normally and not showing signs of illness during the last 3 days leading up to this event;

2. I give my authorisation for the Event Organising Committee to call for veterinary inspection of the horse/s named above and in my care should they be showing signs of illness at any time during the course of the event;

3. I agree to pay any veterinary fees incurred for the abovementioned horse/s as a result of this veterinary examination;

4. The information contained in this Biosecurity Declaration is true and correct to the best of my knowledge;

5. I agree and abide by all conditions that may be imposed at any time by the Event Organising Committee, Facility Coordinator or Council;

6. I acknowledge that in failure to comply, I may be directed to leave and my nominations be forfeited;

7. I acknowledge that decontamination and disinfection procedures may be required of me if instructed by the Event Organising Committee, Facility Coordinator or Council;

8. I acknowledge that there is a possibility that horse/s may become infected with disease agents as a result of my movements and if necessary horses and premises will be quarantined in accordance with any legislation covering such occurrences, including policies and procedures in effect at that time. I agree and acknowledge that the Event Organising Committee, it’s State or National Affiliated bodies and their members, the Facility Coordinator and Council are not in any way liable for any cost, expense, loss, damage, claim, action, proceeding or other liability incurred by or made against me as a result of any movement of horses to the event; and

9. I understand and accept the conditions as noted above.

Applicants Signature: ……………………………………….. Date: ………………………………….

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ANNEXURE ‘D’

HORSE MOVEMENT RECORD – EVENT ORGANISER

Event Title Date:

Arrival PIC Departure PIC Current Hendra Vac Yes No

Horse Registered Name Description / Sex Brand/Microchip Breed

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FORM

Annexure ‘B’ EFT BOND REFUND FORM

All information will be held in the strictest confidence.

To return your completed form or for further information, please contact Council’s Finance Department via email, [email protected], phone (07) 4776 4643, in person at Council’s Main Office, 25 Lannercost Street, INGHAM QLD, or via post to the Accounts Payable Officer, PO Box 366, INGHAM QLD 4850.

EFT PAYMENT CONDITIONS

1. Hinchinbrook Shire Council is under no obligation to verify the accuracy of the bank details provided. Any future changes inbank/company details are to be notified immediately to Hinchinbrook Shire Council in writing to the address above.

2. Payment will be deemed to have been made when Hinchinbrook Shire Council has instructed its bank to credit the aboveaccount.

3. Hinchinbrook Shire Council will take no responsibility for any delays in payments or errors due to factors outside reasonablecontrol of Hinchinbrook Shire Council, including but not limited to delays or errors in the banking system or errors in theaccount details supplied.

4. Hinchinbrook Shire Council reserves the right to, at any time, terminate or suspend this direct credit payment system and tomake payment by other means which may be determined from time to time.

5. The Supplier agrees to return to Hinchinbrook Shire Council, on demand any payments credited to the supplier in error, andHinchinbrook Shire Council reserves the right to off-set the amount of any overpayment made in error against any existing orfuture debit of liability owing by Hinchinbrook Shire Council.

AUTHORISATION

(I/we declare that the information on this form is correct. This authority is signed in accordance with our current bank authorities and/or current company policies)

CONTACT INFORMATION

Name

Address

Phone Mobile Phone

HIRED FACILITY/EQUIPMENT

Details

Bond Refund Requested Date of Hire

PAYMENT DETAILS (EFT)

Bank Name Account Name

BSB Account Number PREFERRED REFERENCE TO APPEAR ON YOUR BANK STATEMENT (limit of 20 characters eg: Hbrook Shire Council – not individual invoice numbers) REMITTANCE ADVICE (please tick preference)

Email Email Address

Post Mail Address

Print Name Phone Number

Signature Date

mailto:[email protected]

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