Contact Name

Email Address

Organisation Name

Organisation Number (ABN, ACN, Qld IA)

Hirer Type Hirer Type Government DGR Charity Other Charity Incorporated NFP Unincorporated NFP Sole Trader Micro Business Other Business Other

Mobile Phone

Other Phone

Postal Address

Activity Type

Activity Frequency Activity Frequency One Off Occasional Monthly (Once a Month) Weekly (One Day per Week) Weekly (Multiple Days per Week)

Frequency Details (Preferred Day and Time Etc)

Activity Description (Include any Noise or Safety Hazards)

Estimated Number of Attendees

Public Liability Insurer Name

Public Liability Insurer Policy Number

Public Liability Insurance Expiry Date

Activity Benevolent Purpose (EG Mental Health)

Priority Need Attendees Priority Need Attendees Children And Young People (Up To 24 Years) Financially Disadvantaged People Indigenous Australians Older People (Aged Over 65 Years) People In Custody And Prisoners People Experiencing, Or At Risk Of, Family Violence People Experiencing, Or At Risk Of, Homelessness People Experiencing, Or At Risk Of, Impaired Mental Heath or Capacity People Residing In Rural Or Remote Areas People Who Are Culturally And Linguistically Diverse People With A Disability Or Mental Illness People With Low Education Levels Single Parents OTHER (Specify Below)

Other Information We Should Know