Doc # 1093227 SL-212 V2
Building consent withdrawal /
refund form
Building consent no.
Name of owner:
Address:
Contact phone:
Email:
Bank account details (for refund if applicable)
Account name:
Account number:
Bank Branch Account no Suffix
Reason for withdrawal:
Signed:
Date:
OFFICE USE ONLY
Approved:
Declined:
Refund amount: Additional charges:
Officer:
Signed: Date:
*A part refund may be applicable depending on the status of the Building Consent at the time of being withdrawn.
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