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Online Form - Renewal of Registration of a Lodging House

For the purpose of applying in conjunction with the Health (Miscellaneous Provisions) Act 1911 for carrying on the lodging house business.

Applicant Details

Applicant Name*

Contact Number*

Email Address*

Postal Address*

Suburb*

State*

Postcode*

Lodging House Details
**The Keeper/ Manager is required to be contactable 24/7 for the purpose of having care and managing the lodging house as per the City of Kalgoorlie-Boulder Consolidated Health Local Laws 2001.

Name of Lodging House*

Registered in the Name of*

ABN*

Premises Address

Street Address:

City:

State:

Post Code:

Country:

Name of Keeper***

Contact Number*

Name of Manager (If different to Keeper)

Contact Number

Total Number of Rooms*

Total Number of Lodgers*

Declaration*

I declare, as the Applicant, all the information supplied on this form is true and correct
I understand that the registration is for the period ending 30 June 2024
I understand that the Keeper/ Manager must reside continuously on the premises
I understand that the City will action this form within 15 working days