Change of details (Deceased)
Mail changes to: PO Box 200, Dandenong 3175

OFFICE USE ONLY	
Date:	/	/	
CSO initials	
Location: Spring		Pkm	D’nong	

PERMIT TYPE	

Disabled Permit	Multi deck Permit	Other permit (please specify) 	

Permit number:	__ 		
DETAILS OF PERMIT HOLDER	

Name:	 	 Address:	 		
NOTIFIED BY	

Name:	 					    Address:	 					    Tel No:				Mobile:		_ Relationship to deceased person	

Signature:

 		Date:  		
Privacy and your personal information:
Council is collecting this information for the purpose of updating records of your registered animals and to forward to you relevant information. The information will  not be disclosed except as required by law. You may access this personal information by contacting Council on 9239 5100. If you fail to provide this information your animal may not be returned to you if lost or stolen.
I do not want the council to use these details to send me information about other services and in general council information.	

Postal Address: PO Box 200 Dandenong 3175	Form updated 09 April 2008