Responsible entity notification form

Entity name (registered):	[Insert Entity Name]
ACN / ABN:	[Insert ACN or ABN]

This notification is made in accordance with the following sections of the Circular Economy
(Waste Reduction and Recycling) (Risk, Consequence and Contingency Plans and Other Matters) Regulations 2023:

Please indicate by selecting the relevant box below:

☐	Regulation 8 (1) A responsible entity must notify the Head, Recycling Victoria that it is a responsible entity in accordance with this regulation.
☐	Regulation 9 (1) An entity must notify the Head, Recycling Victoria that it has ceased to be a responsible entity within 60 days after ceasing to be a responsible entity.

I, [Insert Name] being the [officer of the entity who has control or substantial control over the management [Insert name of the entity, such as the owner, or director] advise that the entity [Insert name of entity (registered)] trading as [Insert trading name] [is or is no longer] a responsible entity within the meaning of section 74A of the Circular Economy (Waste Reduction and Recycling) Act 2021 and regulation 6 of the Circular Economy (Waste Reduction and Recycling) (Risk, Consequence and Contingency Plans and Other Matters) Regulations 2023.

Signed

[Click to enter a date]

[Insert Name]

[Insert Owner / Director / Officer]

[Insert name of responsible entity]

[Insert entity business address (registered)]