Health Premises

Health Premises
Use this form for to update health premises contact deatils, notify Shire of health premises closure, request a copy of health approval documents/certificates
The Shire of Augusta Margaret River collects your personal information to process this request and deliver Shire services. For details on how your information is managed, see our Collection Notices at www.amrshire.wa.gov.au/privacy/collection-notices.

This form is hosted by Jotform (US). By submitting, you acknowledge your information will be transferred outside Australia to a recipient subject to equivalent privacy protections.
I want to
Details being updated
Health Premises Details
Name of health premises
Your Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health premises Address

Street Address

Street Address Line 2

SuburbState

Post Code
Postal Address

Street Address

Street Address Line 2

SuburbState

Post Code
Date of closure

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
File/Photo Upload

Cancelof
As the owner/proprietor I declare that above to be true and correct
Should be Empty:

Health Premises Details