Licensing and Accreditation Regulatory Unit
Declaration for Change in Board Members, Company Directors and Partners of a Firm
Name of Facility
Date of Notification
Licensee Name
(As stated on Licence)
Licensee Type
 Partner of a Firm
 Company or Body Corporate
Trading Name
Company or Partnership Registration Type/Number
NEW BOARD MEMBERS OR COMPANY DIRECTOR OR PARTNER OF A FIRM
Name of New Board Member or Company Directors or Partner of a Firm
Delivering a Healthy WA
Term of Office
1 of 2
Declaration for Change in Board Members, Company Directors and
Partners of a Firm
DECLARATION
I, ……….…………………………………………………………………………………..………….…….....(Print name)
………….………………………………………………………………………………………………...….(Print position)
……………………………………………………………………………………………………………….(Print address)
………………………………………………………….……………………………………………………………………..
………………………………………………………………………………………………………………………………...
declare that:
I have assessed the new Company Director/s of the Body Corporate, new Board member/s or new Partner/s
of a Firm, as applicable, and declare that in relation to





P1.1 – I have assessed the age and identity and they meet licensing requirements
P2.1 & P2.2 – I have attached one character reference and a National Police Clearance Certificate for
each new board member, company director, partner of a firm, as applicable
P2.3 - I have assessed each new board member, company director, partner of a firm, as applicable, and
there is nothing to disclose
P3. – 3.9 - I have assessed each new board member, company director, partner of a firm, as applicable,
and they meet licensing requirements
P4.1 - I have assessed each new board member, company director, partner of a firm, as applicable, and
they meet licensing requirements
The information contained in this declaration is true and correct. I understand that if it is subsequently
established that any information provided is not true and correct, any subsequent licence issued may be
suspended or revoked; and
I am duly authorised to make this declaration.
Name (print)
Position
Signature
Date
Delivering a Healthy WA
2 of 2
2 of 2
Place character reference here.
Place current National Police Clearance Certificate/s here.