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Community Impact Statement Survey

Community Impact Statement Survey

If you would like to contribute to the information within a Community Impact Statement that our office is preparing, then kindly complete the short on-line survey that follows. When you have completed it then please press the submit button only once. A confirmation message will then appear that your survey has been successfully received.

Name / Corporate Name

Address

Contact Person

Telephone Number

Facsimile Number

Email Address

Survey relates to premises at

Message

What is your preferred method for us to contact you?

Phone

Fax

Postal

How far away is the Proposed Premises from where you reside or work? Please distinguish whether the distance is to your place of work or place of residence.

Do you believe the Proposed Premises could adversely affect you, and if so, please specify in what way?

If you believe the Proposed Premises could adversely affect you, can you suggest any changes to the proposal that could lessen your concerns?

For example, you might be aware of operational policies or procedures at a similar venue, which have been successfully implemented at those premises and which, if adopted by this proposal, would satisfy your concerns.

If on the other hand you believe the Proposed Premises could benefit you in some way please indicate in what way.

For example, there may be increased employment opportunities for the community or improved shopping convenience and choice for you.

Do you have any other comments to make regarding the proposal?

Should you have any concerns with the proposal can we contact you to discuss those concerns further?

Yes

If so, we will contact you by your preferred method indicated above. If you ticked by phone, please indicate when would be a convenient time for us to call you, such as at a particular time of the day or day of the week.