Privacy

Privacy Collection Notice

This personal information in this form is collected by Toowoomba Regional Council for the purpose of assessing the request in this form and performing related functions. Council's privacy policy is available at tr.qld.gov.au/privacy.

Applicant type

Is this application for an individual or a company/organisation? *

IndividualCompany/organisation

Applicant details

Title

First name(s)

Last name

Phone number

Email address

Company / organisation details

Company / organisation name *

Australian Business Number (ABN) or Australian Company Number (ACN)

Contact person full name

Phone number

Email address

Secondary contact full name *

Secondary contact phone number

Secondary contact email address

Postal address details

Postal address

Address

Suburb

State

Postcode

Page 2

Memorials & Plaques - Roadside Memorial Application

Structure required

Please select the proposed structure *

White crossOther

Please explain what other structure is proposed

Proposed material of structure

Please select the proposed material of the structure

WoodMetalOther

Please explain your selection of "Other" for the proposed material of the structure

Proposed location

Please provide full details on the proposed location of the memorial *

Page 3

Memorials & Plaques - Roadside Memorial Application

Fees

There is no fee for this application.

Declaration

I understand and acknowledge that:

I submit this application for a roadside memorial in accordance with the terms and conditions of the Toowoomba Regional Council Policy 2.47 Memorials and Plaques and associated local laws.
The information provided in this application are true and complete to the best of my knowledge.
Council may refuse this application if it becomes evident that any information or supporting documents provided is incomplete or false.
I approve of the information that has been provided in this application.
I acknowledge Queensland State Laws will accept this communication as containing my signature within the meaning of the Electronic Transactions (Queensland) Act 2001.

Signature

I agree with the declaration *

Full name of applicant

Date

Form process

After submitting this form a Council officer will contact you (using the details provided in this form) to progress your request, advise if your application has been successful and discuss further arrangements with you.

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