For completion by meter supplier only
For completion by customer only
Postage meter – De-licensing form
ABN 28 864 970 579 G&M#494 June 2014
When to use this form
This form can be used with a letter from the customer requesting their
machine be de-licensed or on its own with the provision the customer
signed this form.
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Your personal information is collected only to enable us to provide you
with the products/services you wish us to provide. The products/
services may not be able to be provided without this information. You
may request access to your personal information while it is stored by
us and we will assess your request in accordance with the law. We will
give you reasons where we deny access. Call 13 13 18 to contact us.
The State Controller
Postage Meter Section
Australia Post
The company listed here has requested the de-licensing of their
postage meter.
Australia Post use only
/ /
No
Yes
Disposal of meter: Supplier disposeCustomer retain
/ /
/ /
/ /
/ /
No
Yes
/ /
We understand that any refund will be processed by Australia Post,
once credit and tote readings are verified with their records, and now
authorise the cancellation of our metering licence. In accordance with
Australia Post procedures, metered spoils have been printed for further
verification and are attached to this authority.
I confirm that the disposal of the postage meter has been done in
accordance with the Australia Post Terms and Conditions.
Signature (customer)
/ /
Date
Name (block capitals please)
Telephone number
Date de-licensing paperwork received
If Yes,
date received
Date licence cancellation finalised in MMM
Date advice sent to LCO
Licence Controlling Office
Address
Company name (Licensee)
Postcode
Company ABN
Position / title
Is a customer authorisation letter attached?
(A customer authorisation letter is not required if this form is signed)
Do you wish to have your refund (if applicable) refunded to your
Australia Post Charge Account?
If Yes,
Account No.
Final meter readings
A: Credit (descending)
Date die withdrawn/disabled
Signature (meter supplier)
Date
Contact name (block capitals please)
Telephone number
$
B: Tote (ascending)
$
C: Control total (A+B)
$
Deductions
$
Amount to be refunded (A – D)
$
D: 2.5 per cent of Credit reading A
Company / business name (meter supplier)
Meter details
Meter serial number
Name of model
Licence number
