Change of Address Form

Blayney Shire Council
CHANGE OF STREET ADDRESS
APPLICATION FORM
This application form is for requests for a property to be known as the address from an alternate street frontage (where the property faces more than one street It is not to be used for the allocation of numbers to newly constructed dwellings. Please include all details as requested. When finished, return this form to Council, including any attachments.
OWNER DETAILS
APPLICANT(S)NAME
POSTAL ADDRESS
PHONE (w)
PHONE (m)
EMAIL
example@example.com
I declare that all the information that I have provided is true and I am authorised to make this application.
Owners Signature

Clear
Owners Signature

Clear
DATE

DayMonthYear
Date
PREMISES DETAILS (Current Street Address)
Street Address
Lot No.
SECTION No.
DP No.
PROPOSED ADDRESS DETAILS
STREET ADDRESS
OTHER
REASON FOR REQUEST TO CHANGE ADDRESS
Please attach relevant documents/maps to enable Council to accurately assess the request

Cancelof
OFFICE USE (Job No. 11400710.166)
Feed Paid
RECEIPT No.
DATE

DayMonthYear
Date
ISSUED BY
Council Details
Blayney Shire Council

91 Adelaide Street, BLAYNEY NSW 2799

PO Box 62 BLAYNEY NSW 2799

Website: www.blayney.nsw.gov.au

Email: council@blayney.nsw.gov.au

Phone: (02) 6368 2104

Change of Street Address – Application Form
Should be Empty:

Blayney Shire Council