Request a Health Business Transfer Form

(under the Public Health and Wellbeing Act)

Please complete this form to receive a Transfer Form for a Health business.

Business Details

Business name

Please provide Business name

Street number

Please provide Street number

Street Name

Please provide Street Name

Suburb name

Please provide Suburb name

Health Licence number if known

Your name

Or the name of the contact person

Please provide Your name

Phone

Please provide Phone

Please check the Email addressPlease provide Email

Fax

Business/Company Name

ABN

Comments/special requirements

For example: your settlement date