Delegation of Authority – Nomination Form

Version: 2016-17 v1
Delegation of Authority – Nomination Form
– THIS FORM IS VALID FOR USE UNTIL 30 JUNE 2017 –
AUTHORISATION DETAILS
1
Name of customer
(a)
Serial number(s) of
entitlements
(b) Property address
2
Person to be authorised
(i)
Name
(ii)
Position
(iii) Phone number(s)
(iv) Email address
(v)
3
Signature of nominee
Period of Authorisation
for current irrigation season 2016/2017
for nominated period
from
to
EXECUTION
(a)
The customer hereby certifies that the above mentioned authorised person has authority to sign on behalf of the customer
for matters relating to short term transfers and water orders pursuant to the Irrigation Right, Delivery Right and Connection
Agreement for the current irrigation season or nominated period.
(b)
The customer hereby agrees that withdrawal or amendment of this authority within the irrigation season or nominated
period must be advised in writing to Tasmanian Irrigation.
(c)
The customer hereby agrees to accept all charges incurred as a result of this authority.
(d)
The customer hereby agrees that they have read and understood Tasmanian Irrigation’s Statement on the Collection and
Use of Personal Information section of this form.
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Version: 2016-17 v1
Signed by the customer:
AS NATURAL PERSONS
SIGNED by Customer 1
SIGNED by Customer 2
Signature
Signature
Name
Name
in the presence of:
in the presence of:
Signature
Signature
Name
Name
Address
Address
SIGNED by Customer 3
SIGNED by Customer 4
Signature
Signature
Name
Name
in the presence of:
in the presence of:
Signature
Signature
Name
Name
Address
Address
AS CUSTOMERS WHO ARE NOT A NATURAL PERSON OR COMPANY
SIGNED for and on behalf of Entity 1 (insert Entity Name)
by:
in the presence of:
Signature
Signature
Name
Name
Position
Address
SIGNED for and on behalf of Entity 2 (insert Company/Entity Name)
by:
in the presence of:
Signature
Signature
Name
Name
Position
Address
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Version: 2016-17 v1
AS CUSTOMERS WHO ARE A COMPANY
EXECUTED by Company 1 (insert Company Name)
EXECUTED by Company 2 (insert Company Name)
under section 127(1) of the Corporations Act:
under section 127(1) of the Corporations Act:
Director:
Director:
Signature
Signature
Name
Name
Director/Secretary
Director/Secretary:
Signature
Signature
Name
Name
HOW TO SUBMIT THIS FORM
Lodge this form by
Mailing to:
Tasmanian Irrigation Pty Ltd
PO Box 84
EVANDALE TAS 7212
Delivering in person at:
Level 2, Terminal Building Launceston Airport,
Western Junction Tasmania
STATEMENT ON THE COLLECTION AND USE OF PERSONAL INFORMATION
Personal information is collected from you by Tasmanian Irrigation Pty Ltd for the purpose of administering and operating
irrigation districts and maintaining public registers of water entitlements in irrigation districts.
Your personal information will be used for the purpose for which it is collected. If the information requested in this form is not
disclosed, your contact details will not be updated by Tasmanian Irrigation Pty Ltd. Personal information may be used by
Tasmanian Irrigation Pty Ltd for:
(a)
updating the contact details of the customer;
(b)
maintaining a register of water entitlements in the irrigation district;
(c)
making information from the register of water entitlement publicly available (including online); and
(d)
for other purposes permitted by the Water Management Act (Tas) 1999, the Irrigation Clauses Act (Tas) 1973 or any
regulations made under those Act as they apply to the irrigation district.
Personal information will be managed by Tasmanian Irrigation Pty Ltd in accordance with the Personal Information Protection Act
(Tas) 2004 and the Privacy Act (Cth) 1988 as applicable and may be accessed by the individual to whom it relates on request to
Tasmanian Irrigation Pty Ltd. You may be charged a fee for this service.
TASMANIAN IRRIGATION PTY LTD
Tasmanian Irrigation Pty Ltd (ABN: 95 722 799 075 / ACN 133 148 384) is a state-owned company responsible for the development
and operation of irrigation schemes in Tasmania. Tasmanian Irrigation Pty Ltd is responsible for approving transfers of water
entitlements and maintaining public registers of water entitlement in respect of each of the irrigation districts it administers.
Address
Level 2, Launceston Airport, Western Junction Tasmania
Postal address PO Box 84, Evandale TAS 7212
Phone
(03) 6398 8433
Fax
(03) 6398 8441
Web
www.tasirrigation.com.au
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