OFFICIAL − Sensitive
Applicant information
Applicant type
Individual/sole trader
Company (body corporate)-To apply on behalf of a company, you must be a director, shareholder or secretary of the company, or be authorised to act on behalf of the company
Partnership
Applicant name (full name of the individual/sole trader, company or partnership applying for the small retail shop certificate)
Applicant contact
Phone*
Mobile
Email*
Other
Registered trading name and location
The retail shop above is/will be trading under the registered trading name of
Shop address*
Suburb/Postcode*
State
Is this business currently operating?*
Yes
No
Date of commencement of operations
Postal address*
Suburb/Postcode*
State
Retail shop operation
The applicant owns and operates the shop referred to above and no other person or body corporate owns or operates the shop
Yes
No
The retail shop above is operated for the benefit of the individual applicant(s) or the members of the applicant body corporate and their respective families
Yes
No
The individual applicant(s) or members of the applicant body corporate are personally and actively engaged in the retail shop
Yes
No
What is the maximum number of persons (including applicant(s) or members of the applicant body corporate) engaged in operating the retail shop at any given time?
How many hours each week are the individual applicant(s) or members of the applicant body corporate engaged in operating the retail shop?
Name Hours
Do any of the individual applicant(s) or members of the applicant body corporate own or operate any other retail shops in Western Australia, either alone or with other people?
Yes
No
If yes, please list all trading names and addresses
Name Address Suburb/Postcode State
Do you trade under a franchise agreement, business lease or any other agreement?
Yes
No
If yes, does the agreement allow for the franchisor or any other person or their agent to enter the shop or assign the right to operate the retail shop?
Yes
No
Does the shop trade under a trust?
Yes
No
If yes, please select which type of trust the shop trades under
Family trust
Unit trust
Discretionary trust
Other
Declaration
I am authorised to make this application as the applicant or member of the applicant group
The information provided in this application is correct, to the best of my knowledge
Privacy Collection Notice

Consumer Protection is a division of the Department of Local Government, Industry Regulation and Safety (LGIRS), and collects your personal information to:

  • Process your application for a small retail shop certificate; and
  • Maintain records of applications, for accountability and reporting purposes.

We may provide this information to:

  • Internal staff to enable the processing and administration of your application.

We will not disclose personal information about you to anybody else, unless you have given consent, or we are authorised or required to do so by law.

Providing the requested information forms part of an application for a small retail shop certificate as required by section 11 of the Retail Trading Hours Act 1987 and associated Regulations. If you choose not to provide it, we will be unable to process your application or issue a certificate.

Please see LGIRS Privacy Policy on our website for more information about how we handle your personal information, how you can request access to, or correction of, the personal information we hold about you, and who to contact if you have a privacy enquiry or complaint.

Submit