<p> CHANGE OF ADDRESS/NAME</p><p>To ensure only authorised changes are made to your name and address data, all information on this form must be completed. REFERENCE DETAILS: Please provide details of all your relevant reference numbers for each area listed below: Shire Rates: (Property / Reference Number(s) (See Rate Notice) Animal Registration: (See Registration Notice) Dog Record Number(s):</p><p>Cat Record Number(s):</p><p>Debtor Accounts: (Account Number(s) Family Day Care, Home Help/Maintenance, (See Invoice)</p><p>CURRENT DETAILS: (Please Print) If a name change is required, please provide documentary evidence of name change. Full Name(s):</p><p>Address: Postcode</p><p>NEW DETAILS: (Please Print) Full Name(s): Date of Birth: (If same ‘as above’) Date of Birth:</p><p>Residential Address: Postcode</p><p>Postal Address: (If same, ‘as above’) Postcode</p><p>Phone Number(s): AH BH Mob Email Address:</p><p>Signature(s): (Must be completed) I/We give permission for the Glenelg Shire Council to use this information to change the address/name details on all Council managed systems. This form must be signed by the property owner, animal owner or debtor. If the property is owned jointly, all property owners must sign. If signed by a power of attorney, a copy of the power of attorney must be provided. If executed by a company, the form must be executed in accordance with the Company’s constitution and the Corporations Act 2001 (C’wealth).   Dated: / / (Owner/Sole Director/Sole Secretary) (Owner/Sol e Director/Sole Secretary) Personal and or health information collected by Council is used for municipal purposes as specified in the Local Government Act 1989. The personal information will be used solely by Council for these purposes and or directly related purposes. Council may disclose this information to other organisations if required by legislation. The applicant understands that the personal and or health information provided is for the above purpose and that he or she may apply to Council for access to and/or amendment of the information. Requests for access and or correction should be made to Council’s Privacy Officer.</p><p>Cliff Street, Portland 3305 PO Box 152, Portland 3305 ABN 48 217 289 490 Office Use Only DWS Telephone: (03) 5522 2200 Fax: (03) 5522 2290 TTY: (03) 5522 2377 Email: [email protected] Website: www.glenelg.vic.gov.au</p><p>CFM-CORPSRv005 Version 2 : Issued 29/06/06</p>