For Heritage Unit Use Only	
Date received	     	
Fee processed	     	
File no.	     	
Database ID:	     	
Date checked	     	
Date provided	     	

ACT HERITAGE REGISTER—REQUEST FOR INFORMATION FORM

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

Information from the Register is available through an online search at www.environment.act.gov.au/heritage/actheritageregister or by phoning
the Heritage Unit on (02) 6207 2166. Note that the status of places and objects 
may change and the version online may need to be updated.

This application form is to be used for:	
1)	A Heritage Register Summary List—list of all places/objects by suburb and district (free download from the Environment ACT Website)
2)	Hardcopies or electronic copies of the individual Register entries—detailing heritage significance (free download at website).
3)	A 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 as this must be applied for using form AF2006-######).
If you need help completing this form, phone (02) 6207 2166. Incomplete or inadequate forms will be returned with feedback.
A fee is payable on receipt of this form, see Fee Schedule. Some exceptions may apply.

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 2006-240  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 Address	     
Suburb	     
State	     
Post Code	
Telephone:	     
Business Hours	     
After Hours	     
Mobile	
     
Email	     
Fax	
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 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
What place or object does this request relate to?	
 Place   Object	Heritage Register ID (if known):      	
Name/s of Place/Object:	     	
Location: 	     
Street No.	     
Street Address	      
Suburb	
     
Block and Section	     
District / Division	
     
Boundary of place (attach map if outside urban area)	
Type:  historic  Aboriginal  natural  other/combined      	
Brief description:      

03	REQUEST FOR INFORMATION FROM THE ACT HERITAGE REGISTER
What do you require?
 Heritage Register Certificate (hardcopy only)
Formal evidence of heritage status of place or object, registered or not
 Heritage Register List—list of all places/objects by suburb and district (free download on website)
 Heritage Register entry—Nomination Summary. Provisional Register or Register (free download on website)
 other      	
What format/s do you require?
 hardcopy                                    email attachment
 computer disk or CD ROM         other     

‘I request the above information in accordance with the Heritage Act 2004. The information provided here is accurate to the best of my knowledge.’	
Your identity is protected under the Federal Privacy Act 1988 and will not be divulged without your consent or as allowed for under that Act.	

Signed:  ______________________________	
Date: