ACT HERITAGE REGISTER
					AF2014-105
For ACT Heritage Use Only	
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ACT HERITAGE REGISTER—
Information Request Form
Heritage Act 2004, s18

The ACT Heritage Register contains details of places and objects of significance to the ACT.

Information from the Register is available through an online search at www.environment.act.gov.au/heritage, by contacting ACT Heritage on 13 22 81 or by emailing heritage@act.gov.au. 

Please note that the status of places and objects may change and the online version may not be up to date.

This information request form is to be used for:
1.	A Heritage Register Summary List – list of all places/objects by suburb and district (free download can also be obtained from the website)
2.	Hardcopies or electronic copies of individual Heritage Register entries, detailing heritage significance (free download can also be obtained from the website)
3.	A Heritage Register Certificate – this is recommended where formal evidence is required to confirm current registration status
4.	Other requests for Heritage Register information (excluding restricted information, which requires a separate form to be completed).

A fee is payable on receipt of this form. A schedule of fees is available on ACT Heritage’s website at www.environment.act.gov.au/heritage. 

DO YOU REQUIRE MORE INFORMATION OR NEED HELP?
If you need help completing this form, contact ACT Heritage on 13 22 81 or 
email heritage@act.gov.au. Incomplete or inadequate forms will be returned with feedback.

More information about the ACT Heritage Council, the Heritage Register and the heritage registration process
is available on the ACT Heritage website at www.environment.act.gov.au/heritage 
or by contacting ACT Heritage on 13 22 81 or by email at heritage@act.gov.au. 

LODGING YOUR FORM
Please send this form
o by mail to: The ACT Heritage Council, PO Box 158, Canberra  ACT 2601; 
o by hand to: ACT Heritage, Dame Pattie Menzies House, 16 Challis Street, Dickson ACT
o	 by email to: heritage@act.gov.au 

An Information Request Form will not be accepted unless signed and dated.

01 YOUR DETAILS
Name:		________________________________________________________________
Title		First Name			Surname
Organisation	________________________________________________________________
Organisation Name (if the organisation is the nominator)	Position
Postal Address:________________________________________________________________
Postal Address					State	Postcode
Telephone:	________________________________________________________________
Business Hours		After Hours		Mobile
		_______________________________________________________________________________
Email

How would you describe yourself?
someone considering buying an interest in the land;
an owner 	  occupier      lessee or sublessee or     a person in possession of the object;
an architect or designer of a building or structure at the place or      a maker of the object;
the nominator (s.28) or      a reporter of a discovered Aboriginal place or object (s.51);
a person with traditional (Aboriginal) affiliation, for an Aboriginal place or object;
a representative Aboriginal organisation (under s.14)
other

02 DETAILS OF PLACE OR OBJECT
Place 		Object 
Type: 		 natural 	Aboriginal 	 historic		other/combined

Name of place/object:	_________________________________________________________
Other names if any:	_________________________________________________________
Location:	________________________________________________________________
Address							Suburb
_______________________________________________________________________________________________
Block/Section/District/Division (If multiple addresses or blocks and sections, list all)
______________________________________________________________________________________________
Description of place’s boundary or objects components

03 REQUEST FOR INFORMATION FROM THE ACT HERITAGE REGISTER 
What do you require:

	Heritage Register Certificate		Heritage Register List
Heritage Register Entry			Other

What format/s do you require?

	Hardcopy		email attachment
	CD ROM		other

04. PERSONAL INFORMATION DISCLOSURE STATEMENT

The personal information on this form is provided to the ACT Heritage Council and ACT Environment and Planning Directorate for the purpose of processing your request for information. If you do not provide your contact details, the Heritage Council will not be able to process your application EPD’s Information Privacy Policy contains information about how you may access or seek to correct your personal information held by EPD, and how you may complain about an alleged breach of the Territory Privacy Principles. The EPD Information Privacy Policy can be found at www.act.gov.au/epd/information_privacy. 

I request the above information in accordance with the Heritage Act 2004. The information provided here is accurate to the best of my knowledge.

I understand that giving false or misleading information is a serious offence under the Criminal Code 2002.

Signed: ______________________________ 

Date: _________________