Amended Appendix A - DA Form 1

PART 9 – FOR OFFICE USE ONLY

 Date received:                                   Reference number(s):

 Notification of engagement of alternative assessment manager
 Prescribed assessment manager
 Name of chosen assessment manager
 Date chosen assessment manager engaged
 Contact number of chosen assessment manager
 Relevant licence number(s) of chosen assessment
 manager

 QLeave notification and payment
 Note: For completion by assessment manager if applicable
 Description of the work
 QLeave project number
 Amount paid ($)
 Date paid
 Date receipted form sighted by assessment manager
 Name of officer who sighted the form

The Planning Act 2016, the Planning Regulation 2017 and the DA Rules are administered by the Department of
Infrastructure, Local Government and Planning. This form and all other required development application materials should
be sent to the assessment manager.




                                                                                                                      Page 11
                                                                                    DA Form 1 – Development Application details
                                                                                                      Version 1.0—3 July 2017