Signed_CouncilCDAForm · 132005.1133.06

OFFICE USE ONLY
Application no.      Amount paid         Date paid            Receipt no.          Initial              Date stamp


Receiving Officer




Payment options
In person     9 Pelican Street, Tewantin: 8.30 am to 4.30 pm Monday to Friday (excludes public holidays).
By mail       Cheque or money order to be made payable to Noosa Council.
                  Cheque                       Money order                    Mastercard                    Visa
              Card number                                                  Expiry date                   Amount $
              Name on card                                                 Signature of cardholder
              Phone                                                      Is a receipt required?              Yes            No
All payments made by credit card will incur a 0.50% surcharge (exempt of GST) to reflect the cost of fees charged for credit card
transactions.

                                                                                                                           Page 4 of 4