For Heritage Unit Use Only	
Date received	     	
Fee processed	     	
File No.	     	
Database ID	     	
Date Checked	     	
Approved?	     	

ACT HERITAGE REGISTER— REQUEST FOR RESTRICTED INFORMATION FORM

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

This application form is for access to and/or publishing of Restricted Information under the Heritage Act 2004. In some instances the Heritage Council can declare particular information to be restricted (Heritage Act 2004 s 54) to prevent substantial adverse effect on the heritage significance of a place or object. It is an offence to knowingly publish this information without formal approval (Heritage Act 2004 s 55).

Applications must be made under s 56 to access this information or for approval to publish except in some limited exceptions. The exceptions are stated under s 55 or s57 of the Heritage Act 2004.

The Heritage Council is under no obligation to approve the access or publishing of restricted information and may not do so if it considers it possible that by doing so there may be a substantial adverse effect on the heritage significance of the place or object.

For each Approval of Restricted Information a fee is payable on receipt of this form. Additional charges may apply for large requests, see Fee Schedule. For people with traditional affiliations who meet the requirements of s 55 of the Act, this form is optional and no charges apply. If you need help completing this form, contact (02) 6207 2166.

DO YOU REQUIRE MORE INFORMATION OR HELP?

For further help, contact the Heritage Unit on (02) 6207 2166 or email heritage@act.gov.au

For more information on the ACT Heritage Council, the Heritage Register or the heritage registration process, please download the relevant information sheets available on the Environment ACT Website at www.environment.act.gov.au under Heritage or by contacting the Heritage Unit.

Approved form AF 2006-239 approved by John Hargreaves MLA, Minister for the Territory and Municipal Services on 9 August 2006 under s119 Heritage Act 2004 (approved forms)

LODGING YOUR FORM
Please send this form
o	by mail to:	The ACT Heritage Council, PO Box 158, LYNEHAM ACT 2602 
o	by fax to:	(02) 6207 2200
o	or by hand to:	The ACT Heritage Council, c/o Heritage Unit, Level 2 Tower, Macarthur House, 
12 Wattle Street, Lyneham 

And if possible, email an electronic copy to heritage@act.gov.au. Blank forms are available on the Environment ACT website, however the form will not be accepted without a hardcopy with a signature.

01	YOUR DETAILS
Name:	      
Title	      
First Name	      
Surname	
Organisation 	      
Name of Organisation	      
Position	
Postal Address:	     
Street No.	      
Street Name	      
Suburb	    
State	     
Post Code	
Telephone:	      
Business Hours	      
After Hours	      
Mobile	

Email	     
Fax	

02	ELIGIBILITY
For people with traditional (Aboriginal) affiliation:
Under the Heritage Act 2004 (Section 55(3)):
   I am a person with traditional (Aboriginal) affiliation with the place or object; and 
   am publishing the information myself; and
 my purpose is:
 to give to another Aboriginal person; or
 to educate about Aboriginal tradition; or
 necessary and reasonable to avoid an imminent risk of damage to, or destruction of, an Aboriginal place or object
 	
Where land is for sale:
Application for limited access to Restricted Information under the Heritage Act 2004 (Section 57) on a need to know basis and not for publication:
 The land is currently offered for sale:  sale notice/advertisement attached; and 
 I am an “interested person” (i.e. one or more of the following) applying to access restricted information relevant to the conservation and use of the land:

For a place:
  an owner;  an occupier;  a lessee or sublessee;  an architect or designer of a building or structure at the place;  the nominator (s28)

For an object:
  an owner;  a person in possession of the object;  a maker;  the nominator (s28)

For an Aboriginal place or object:
 a representative Aboriginal organisation (s14);
 a reporter of a discovered place or object (s51);

Others:
 the Planning and Land Authority;
 the Conservator of Flora and Fauna; or
 the National Capital Authority; or

  I am a person considering buying an interest in the land applying to access to restricted information relevant to conservation and use of the land

 Other circumstances: 
(i.e. other applicant seeking approval for publication of restricted information under the Heritage Act 2004 (Section 56))
 heritage professional (State professional qualifications:                                                 ); or

 other      

03	REQUEST FOR INFORMATION, FOR ACCESS OR PUBLICATION
”Publication” can include any form of verbal or written distribution including web-based
What place or object does this application relate to?	
 Place   Object	Heritage Register ID (if known):      	
Name/s of Place/Object:	     	
Location: 	      
Street No.	      
Street Name	      
Suburb	
     
Block and Section	     
District/ Division	
     
Boundary of place (attach map if outside urban area)	
Type:  historic  aboriginal  natural  other/combined      	
Brief description:      		
What details do you require?
 restricted location details        
 restricted details of site name/type     
 the Restricted Heritage Register entry (i.e. all restricted details)
 other      		
Do you propose to publish? 
 no, own use only – note that information must not be knowingly transmitted to third parties including your agents and other eligible parties. They must apply separately.
 yes:	
1)	State the reason for publication
     	
2)	State the nature of the publication, i.e. the type of publication method, proposed date
      	
3)	State the person, people or kind of people to whom it would be directed 
     

‘I am applying for Restricted Information from the ACT Heritage Register in accordance with the Heritage Act 2004. The information provided here is accurate to the best of my knowledge.’
  ‘I have read and understood the provisions of Sections 55, 56 and 57 of the Heritage Act 2004’. The sections of the Act are attached with the form.

Signature	      
Date