(For use only in case of an address for service changed by a public authority, without change of premises) The change of address for the entry of which application is mad on the other side of this form, was ordered by (a) ………………………………………….. ……………………………………………………………………………….. (a) Here insert the name of the public authority ordering the change and the date thereof. on the ………………………….day of………………………………, 20…… Dated this………………………day of………………………………, 20….. (b)………………………………………………………….. ____________________________________________________________ NOTE: If the above statement be made, and a certificate of the alteration given by the named authority be supplied, the Registrar, if satisfied as to the facts of the case, will not require a free to be paid. (See regulation 71) 2066 (b) Signature of the Registered Proprietor or Registered User as the case may be.