Annual Statement by a Licensed Credit Provider
(Body Corporate)
Please use a pen and write neatly using BLOCK LETTERS. Tick where appropriate ;
This annual statement must also be accompanied by the prescribed fee and those additional items listed in
the attached checklist.
1. Applicant Details
Department of Consumer &
Employment Protection
Ground Floor “Forrest Centre”
219 St Georges Terrace
PERTH WA 6000
Locked Bag 14
Cloisters Square WA 6850
Licensing Advice Line
8:30am to 5.00pm
Monday to Friday
Tel: 08 9282 0833
Fax: 08 9282 0559
Country Callers
1300 30 40 54
Web Site
www.docep.wa.gov.au
Licence Number
Name of Body Corporate
ACN
ABN
Business Name(s)
Attach additional sheet if necessary
Since the grant of the licence or since the last annual statement, whichever is the later, has the company
changed its name or changed the business name(s) under which it operates its credit providing
business?
Yes / No
Attach a page detailing any changes together with any certificate(s) of change of company name or certificate(s) of
registration of any new business name(s)
Principal Place of Business
If no place of business in Western Australia insert
the principal place of business in Australia
Primary Postal Address
If different than above
Other Place(s) of Business
Phone and Fax Numbers
Ph
F
( )
( )
Email Address
Registered Office Address
If body corporate was not incorporated in Australia
provide the address of the body corporate’s principal
office in Australia
Yes / No
During the last year, did the body corporate carry on business as a credit provider in partnership with
another person?
If the answer is ‘Yes’ please provide the following details for each partner or proposed partner:
Full name
Address
Attach additional sheet if necessary
NOTE: It is an offence, with a maximum fine of $5,000, for the holder of a credit provider’s licence to carry on a
business of providi