For Heritage Unit Use Only	
Date received	     	
Fee processed	     	
File No.	     	
Database ID	     	
Date to Council	     	
Decision date	     	
Accepted?	     	

ACT HERITAGE REGISTER—NOMINATION FORM 
(INCLUDING A REQUEST FOR AN URGENT DECISION)

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

This application form is to nominate a place or object to the ACT Heritage Register. Any person can make a nomination. In making this application, you are asked to identify its potential heritage values and provide supporting evidence.
This application form can also enable you to apply for an urgent decision by the ACT Heritage Council
Applications for an urgent decision must include a current heritage significance assessment prepared by an appropriately qualified professional and pay the fee
The ACT Heritage Council will use its best endeavours to decide within 20 working days after the day it receives the application, whether or not to provisionally register the place or object nominated (under s 29 Heritage Act 2004). A Provisional Registration or Statement of Reasons will be issued as soon as practicable once the decision has been made.
No fee is payable for standard nominations. For each Application for Urgent Decision a fee is payable on receipt of this form, see Fee Schedule. If you need help completing this form, contact (02) 6207 2166. Incomplete or inadequate forms will be returned with feedback.

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 2006-241 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	APPLICATION FOR URGENT DECISION	
The ACT Heritage Council will use its best endeavours to decide within 20 working days after the day it receives the application, whether or not to provisionally register the place or object nominated (Heritage Act 2004 s 29). A Provisional Registration or Statement of Reasons will be issued as soon as practicable once the decision has been made.	

Are you requesting an urgent decision on this nomination from the ACT Heritage Council? 
 yes
        Provide a reason for this request:       
        Provide a current heritage significance assessment prepared by an appropriately qualified professional      
      Note this form will not be accepted until a full payment has been received.
 no    - go to Section 02	

02	DETAILS OF NOMINATED PLACE OR OBJECT
 Place    Object	Type:  historic  Aboriginal  natural   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	
For Aboriginal places, natural or rural locations: attach a sketch map, map references and/or GPS coordinates.  
Exact locations of Aboriginal places are treated as restricted information and should not be divulged to other parties. Additional forms for Aboriginal places can be provided to relevant qualified professionals.	

03	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	
	     
Fax	     
Email	
Do you have any personal association with the place or object?     yes   no
If yes, how would describe yourself: 
 owner  tenant  neighbour 
 a person with traditional (Aboriginal) affiliation with the place or object 
 other        

04	DETERMINING HERITAGE SIGNIFICANCE

For each criterion please indicate how well you would rate this place and or object. Ratings against each are:

High = meets to a high degree: excellent example or unique, with strong evidence provided.	
Meets = meets to a limited degree: one of a number, demonstrated some features, and/or has limited supporting evidence eg documentation is limited.	
Not Met / NA = does not have supporting evidence to demonstrate it meets this criteria or is not applicable.	

For a place or an object to be determined as having heritage significance it must satisfy one or more of the legislative criteria:

(a)	it demonstrates a high degree of technical or creative achievement (or both), by showing qualities of innovation, discovery, invention or an exceptionally fine level of application of existing techniques or approaches;	 High
 Meets
 Not Met / NA	
(b)	it exhibits outstanding design or aesthetic qualities valued by the community or a cultural group;	 High
 Meets
 Not Met / NA	
(c)	it is important as evidence of a distinctive way of life, taste, tradition, religion, land use, custom, process, design or function that is no longer practised, is in danger of being lost or is of exceptional interest;	 High
 Meets
 Not Met / NA	
(d)	it is highly valued by the community or a cultural group for reasons of strong or special religious, spiritual, cultural, educational or social associations;	 High
 Meets
 Not Met / NA	
(e)	it is significant to the ACT because of its importance as part of local Aboriginal tradition;	 High
 Meets
 Not Met / NA	
(f)	it is a rare or unique example of its kind, or is rare or unique in its comparative intactness;	 High
 Meets
 Not Met / NA	
(g)	it is a notable example of a kind of place or object and demonstrates the main characteristics of that kind;	 High
 Meets
 Not Met / NA	
(h)	it has strong or special associations with a person, group, event, development or cultural phase in local or national history;	 High
 Meets
 Not Met / NA	
(i)	it is significant for understanding the evolution of natural landscapes, including significant geological features, landforms, biota or natural processes;	 High
 Meets
 Not Met / NA	
(j)	it has provided, or is likely to provide, information that will contribute significantly to a wider understanding of the natural or cultural history of the ACT because of its use or potential use as a research site or object, teaching site or object, type locality or benchmark site;	 High
 Meets
 Not Met / NA	
(k)	the place exhibits unusual richness, diversity or significant transitions of flora, fauna or natural landscapes and their elements;	 High
 Meets
 Not Met / NA	
(l)	the place is a significant ecological community, habitat or locality for any of the following:
(i)	the life cycle of native species;
(ii)	rare, threatened or uncommon species;
(iii)	species at the limits of their natural range; or
(iv)	distinct occurrences of species.
	 High
 Meets
 Not Met / NA	

05	YOUR STATEMENT OF SIGNIFICANCE

What is it that is significant? (e.g. why is it unique or the best example of its type)
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To whom is it likely or known to be significant? (e.g. a region or group within the ACT, the whole of the ACT, a specific community)
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How and why it is significant? (including an explanation for each criterion rated as High or Meets)

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06	FURTHER SUPPORTING INFORMATION, IF KNOWN
Additional attachments can also be provided

Provide any known details for the owner/s, unless  same as nominator	
Current owner:	      
Name (attach additional details if multiple owners)	
Address:	      
Postal or Street Address	      
State	     
Postcode	
Telephone:	      
Business Hours	      
After Hours	      
Mobile	
	     
Fax	     
Email	
Is the owner/s aware of the nomination?  no   yes  some are (indicate which if multiple owners)	
Does the owner/s support this nomination?  no  yes,  some do, attach letter/s of support if possible	

Designer or architect: _______________________________________________________________________
Creator or builder: __________________________________________________________________________
Date built/made:    Year started:        Year finished:               Circa (if dates approximate e.g. c.1920-30)
Brief history: include key dates and any major changes such as changes of use or ownership.
__________________________________________________________________________________________
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Key significant (or intrinsic) features:  (e.g. interiors, exterior elements, archaeological, landscape or natural features, for objects give number and dimension/s.)
__________________________________________________________________________________________
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Current physical condition: (covering key features and attach photographs)
__________________________________________________________________________________________
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Imminent threats to its significance _____________________________________________________________
__________________________________________________________________________________________

Other heritage listings:
       	National Heritage List
      	Commonwealth Heritage List
      	Register of the National Estate
      	National Trust of Australia	
	Royal Australian Institute of Architects
	Other/s      
     	
For websites to look up these listings, go to the Heritage Legislation Information Sheet 4—What is the Register? at www.environment.act.gov.au/heritage under Heritage Legislation.	

Supporting Documentation: Please list any further documentation that will support this nomination, 
e.g. historic documents, maps or photos, written histories, oral histories, heritage assessment reports (include author, date and name), site recording forms for Aboriginal places/objects (contact the Heritage Unit for blank forms).

Author/s or Source	Title/Description	Date	

			

List all attachments enclosed:
	______________________________________________________
	______________________________________________________
	______________________________________________________

‘I wish to nominate this place or object to the ACT Heritage Register in accordance with the Heritage Act 2004. The information provided here is accurate to the best of my knowledge and may be made publicly available for the purpose of registering this place or object unless otherwise indicated.’
   ‘I allow for my name/organisation to be disclosed as the nominator.’  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: