APPLICATION & DECLARATION
The Council relies on the information contained in this application being complete and accurate. The Applicant must take all reasonable
steps to ensure that it is complete and accurate and accepts responsibility for information in this application being so.
If lodging this application as the Applicant:
I/we hereby represent and warrant that I am/we are aware of all of my/our obligations arising under
this application including, in particular but without limitation, my/our obligation to pay all fees and
administrative charges (including debt recovery and legal expenses) payable under this application as
referred to the Fees Information section.
If lodging this application as agent of the Applicant:
I/we hereby represent and warrant that I am/we are authorised to act as agent of the Applicant in
respect of the completion and lodging of this application and that the Applicant is aware of all of his/
her/its obligations arising under this application including, in particular but without limitation, his/her/
its obligation to pay all fees and administrative charges (including debt recovery and legal expenses)
payable under this application as referred to the Fees Information section.
Signed (by or as authorised agent of the Applicant) **
Full name of person lodging this form
**If this form is being completed on-line you will not be able, or required, to sign this form and the on-line lodgement will be treated as
conrmation of your acknowledgement and acceptance of the above responsibilities and liabilities and that you have made the above
representations, warranties and certication.
The information you have provided on this form is required so that your application can be processed under the Resource Manage-
ment Act 1991 and may also be used in statistics collected and provided to the Ministry for the Environment and Queenstown Lakes
District Council. The information will be stored on a public register and may be made available to the public on request or on the
company’s or the Council’s websites.
An initial fee for processing this application will be charged at the time of lodgement in accordance with QLDC’s fee schedule. This
initial fee must accompany your application for processing to commence. If the initial fee is insucient to cover the actual and
reasonable costs of work undertaken on the application you will be required to pay any additional amount and will be invoiced
monthly as work on the application continues. Please note that if the Applicant has outstanding fees owing to Council in respect of
other applications, Council may choose to apply the initial fee to any outstanding balances in which case the initial fee for processing
this application may be deemed not to have been paid.
Invoiced sums are payable by the 20th of the month after the work was undertaken. If unpaid, the processing of an
application, provision of a service, or performance of a function will be suspended until the sum is paid. You may also be
required to make an additional payment, or bring the account up to date, prior to milestones such as notication, setting a
hearing date or releasing the decision. In particular, all charges related to processing of an application are payable prior to
issuing of the approval. Payment is due on the 20th of the month or prior to the issue date – whichever is earlier.
LIABILITY FOR PAYMENT – Please note that by signing and lodging this application form you are acknowledging that the
Applicant is responsible for payment of invoices and in addition will be liable to pay all costs and expenses of debt recovery
and/or legal costs incurred by QLDC related to the enforcement of any debt.
INFORMATION TO BE SUBMIT TED // Attach with this form
Completed Subdivision 224c Checklist
All correspondence documents in regards to the conditions
Please ensure documents are scanned at a minimum resolution of 300 dpi
Each document should be no greater than 10mb
Please upload via our Sharefile portal or send directly to firstname.lastname@example.org
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
Page 4/4 // June 2017
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