Change of Entity - LeavePlus

CURRENT DETAILS
LeavePlus Employer Member Number*
Registered Business Name*
Business Type
ABN*
Phone Contact Number*
Email Address*
CHANGE OF ENTITY DETAILS
TRADE TYPE
Industry Sector*
Work Performed*
Industry Type*
Employing in Victoria?*
- Yes
- No
Is the new entity accepting financial responsibility for any debt incurred under the previous entity?*
- Yes
- No
Date employment commenced under new entity*

Day
Month
Year
BUSINESS DETAILS
Registered Business Name*
Trading As
Business Type*
ABN*
BUSINESS CONTACT DETAILS
Main Telephone Number
Main Mobile Number*
Business Email Address*
Address*
Address Line 1 Address Line 2 Suburb State Post code Country

Cannot be a PO Box Address.
Is the Postal Address different to Site Address?*
- Yes
- No
POSTAL ADDRESS
Address Line 1 Address Line 2 Suburb State Post code Country
BUSINESS OWNER / COMPANY DIRECTOR
Owners / Directors
Name Actions
There are no Owners / Directors.
Maximum number of owners / directors reached.
CONTACT DETAILS
Contact
Name Actions
There are no Contacts.
Maximum number of contacts reached.
WORKERS
Transfer All Workers?*
Worker details
Name Actions
There are no Workers.
Maximum number of workers reached.
DECLARATION
Consent*
I declare that, to the best of my knowledge, all the information I have provided is true and correct. I authorise LeavePlus to engage with my representative on my behalf upon receipt of this authority.*
Name*
First Last
Declaration Date
DD slash MM slash YYYY

Name	Actions

There are no Owners / Directors.

Name	Actions

There are no Contacts.

Name	Actions

There are no Workers.

Your information will be stored and used by LeavePlus and its contracted service providers in delivering its services. It will not otherwise be used or disclosed unless that use or disclosure is required or permitted by law. You may apply for access to, and/or amendment of, your information by emailing LeavePlus at info@leaveplus.com.au, writing to LeavePlus at GPO Box 4368, Melbourne VIC 3002 or calling LeavePlus on 1300 264 683. For further information on how your personal information is handled, visit LeavePlus’ Privacy Policy at https://www.leaveplus.com.au/about-us/privacy/.

CURRENT DETAILS

CHANGE OF ENTITY DETAILS

TRADE TYPE

BUSINESS DETAILS

BUSINESS CONTACT DETAILS

BUSINESS OWNER / COMPANY DIRECTOR

CONTACT DETAILS

WORKERS

DECLARATION