Application for Temporary Place of Assembly

Application for Temporary Place of Assembly (Event) Form

Public Health Act 1997 - Sections 76 & 81

This form ONLY needs to be completed if your event will have one thousand people or more, present for two hours or more.

Please complete this form if you wish to apply to operate a temporary place of assembly for a specific event.

This process should take approximately 10 minutes to complete.   Once you have completed the form it will be lodged with Council and you will be emailed a copy of your licence within up to ten (10) working days.

Please note that there is a fee for this application. 

After you have submitted the application form, you will be contacted with an application number for payment.

Payment can be made in person during Council business hours or by credit card over the phone on (03) 6211 8200.

Please refer to Council’s fee schedule for the relevant fee.

You must complete this form two weeks prior to the date of the event.

Please remember to:

•Include as much detail as possible.

•Provide an answer to every question.

•Tick all of the confirmations to allow the generation of your certificate.

•Display the certificate on the day.

•Contact an Environmental Health Officer on (03) 6211 8255 if you need assistance.

Please be aware that events may be inspected by an authorised officer and enforcement action may be taken where non-compliances are noted.


Special Application for Temporary Place of Assembly (Event) Form

* Mandatory Field

Event Information
Event Information
Name of event*
Location of Event*
Date of event
Start Time*
Finish Time*
Application Details
Applicant Name
Applicant Name*
Applicant Address*
Contact Phone or Mobile*
Contact Email*

(please supply an email address so we can email your certificate to you)

Has your organisation applied to Kingborough Council for a temporary place of assembly licence previously*
Do you have land owner consent to hold your stall/event on their land?*

(if your stall will be on council land please contatct Council's Community Liaison Officer on (03) 6211 8200)

Event Information
Event Information
Emergency Contact (name) for the Event*
Emergency Contact (mobile) for Event*
Anticipated maximum number of person to attend event overall*
Anticipated maximum number of persons at peak occupancy (ie – at any one time of the day):**
Number of Male Toilets
Hand Wash Basins*
Number of Female Toilets
Toilets (f)*
Hand Wash Basins (f)*
Number of Disabled Toilets
Number of Toilets with Disabled Access*
Number of Toilets without Disabled Access*
Unisex Toilets*

Please state if any of the above will be Unisex instead of seperate male/female

Does your event require a Public Event Smoke-Free Management Plan to be approved by the Department of Health and Human Services (DHHS)?*

If unsure, click here: *

Please upload a copy of the plan for the event in pdf,doc,docx,jpeg

Are there any other licences issued to the event?:**
Please Specify Other Licenses Issued

Please upload a copy of the site plan for the event in pdf,doc,docx,jpeg

If your form has been submitted correctly you will see a confirmation page.
If you get a 'Forms Submission Error' it means one or more of the mandatory fields have not been filled in.


1. I have inserted and completed any and all information required on this application; and

2. I declare that all information on this application is true, accurate and complete; and:

3. I acknowledge that this application is not valid and assessment of the application will not commence until all application fees are paid in full; and

4. I agree to comply with all requirements stipulated by Council's Environmental Health Officer and the conditions as set out on the Temporary Place of Assembly Licence; and

5. I agree to keep a copy of Council's Temporary Place of Assembly Licence at the event; and

6. I acknowledge and agree that if an email address is provided on this application I consent pursuant to Section 6 of the Electronic Transactions Act 2000 to the Council using that email address as a method of contact and for the provision of information by the Council; and

7. I understand that by submitting this application it is a legal document and the person named on the licence is responsible for compliance with stipulated conditions.

If you see this, leave this form field blank.
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