ABN: 50 860 676 021 Heavy Vehicle Operations 525 Great Eastern Highway REDCLIFFE WA 6104 Telephone: 138 486 Facsimile: (08) 9475 8455

Please accept this format notification that I wish to retire from the WA Heavy Vehicle Accreditation Scheme. DATE: ___/___/___ ACCREDITATION APPROVAL NO: NAME OF ACCREDITED COMPANY: PHONE NO: FAX NO: AUTHORISED BY: (Signature) (Print Name) POSITION/TITLE: ***Please be aware that retiring from WA Heavy Vehicle Accreditation will result in the cancellation of any permits attached to above mentioned accreditation including the permits of any sub contractor also approved to operator the accreditation*** PLEASE RETURN BY FAX TO: 9475 8455 PLEASE PROVIDE A BRIEF REASON FOR RETIREMENT FROM ACCREDITATION: