This form is to be completed for a Hydroponic Equipment Dealer’s Licence. For an individual complete parts A & D, for a Company complete parts B, C & D. In addition to completing this application, a Hydroponics Industry Personal Information Declaration (PID) must be completed for each individual licence applicant or in the case of a company, each director. All details must be completed to the best of your knowledge. It is an offence to make a statement that is false or misleading (whether by reason of inclusion or omission on any particular) in any information provided. If you have any doubt about a question please contact the Licensing Enforcement Branch on (08) 7322 3342.
SAPOL use only	Licence No:	Application Ref:
A. INDIVIDUAL APPLICANT DETAILS
Family Name	Given Name(s)
Male Female	/ /
Date of Birth	Occupation
Current Residential Address	Post Code	State
Service Address (This is the address any official correspondence will be sent to)	Post Code	State
( )	( )
Home Phone	Work Phone	Mobile
Email
B. COMPANY APPLICANT DETAILS
Company Name
Address	Post Code	State
Service Address (This is the address any official correspondence will be sent to)	Post Code	State
( )	( )
Phone	Mobile	Facsimile
Email
Contact Person Family Name	Contact Person Given Name(s)
( )
Phone	Mobile
Email

Application Ref:
C. COMPANY DIRECTORS DETAILS
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
Family Name:	Given Name(s):
Residential Address:	DOB:	/ /
D. TRADING NAMES & ADDRESSES