Architects Act 2004 – s92 Notification - intention to use the

  A3 	

term Architect and Registered Architect

Interstate registrant details

Privacy information

Information you are asked to provide will be used to assess your ability to hold registration as an Architect in the ACT.

Title

Given names

Residential address

Business address

Home phone

Surname

Date of birth	/	/

Territory/State	Postcode

Territory/State	Postcode
Business phone

The lawful authority for the collection of this information is the Architects Act 2004. The  information  may  be disclosed to other architect registration authorities.

Note

Should  your  registration within the State/Territory of which you hold residence expire,    be    cancelled, suspended	and/or disqualified this notification will  be  subject  to  your eligibility.

Mobile phone	Facsimile

Email

Registration details for State/Territory where you hold residence

State/Territory	Date first registered	/	/

Registration No.	Registration expiry date	/	/

Please attach to this notification a certified copy of photo identification which contains your current residential address

Questionnaire

No	Yes

No	Yes

No	Yes

No	Yes

Have you been bankrupt, or are applying to take the benefit of any law for the relief of bankrupt or
insolvent debtors, or compounding with creditors or making an assignment of remuneration for the
benefit of creditors?
Have you been convicted or found guilty of an offence against the Architects Act 2004 or the repealed Architects Act 1959?
Have you been convicted or found guilty of an offence against a Commonwealth Territory or State law punishable by imprisonment for 1 year or longer?
Have you ever had Architects Registration disqualified, cancelled or suspended under the corresponding laws of any other State or Territory?

If you have answered ‘Yes’ to any of the above questions please provide details:  ........................................................................................

Office use only

Date received

/	/

Receiving officer

..............................................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................................................

Declaration

Approved

I declare that the information contained in and attached is complete, accurate and true to the best of my knowledge.
I understand that there are severe penalties for providing false or misleading information and am aware of my responsibities as stipulated within the ACT Architects Act 2004.

Yes	No

Signature

Date	/	/

A3	Payment details for financial year 2010-2011
NOTE:  Intention to use the term Architect	$19.70  (GST does not apply)

Cheques should be made payable to the “Receiver of Public Monies”.
Please provide your name and address on the back of the cheque.

Payment options
IN PERSON - present your cash, cheque, money order or credit/debit card ($5000.00 maximum payment for credit card) at the ACT Planning and Land Authority Shopfront, ground floor, south, Dame Pattie Menzies House, 16 Challis Street, Dickson, ACT (8:30 am to 4:30 pm Monday to Friday except public holidays).

BY FAX - complete the credit card details and payment details ($5000.00 maximum payment for credit card) then fax
it to ACT Planning and Land Authority on fax number (02) 6207 1925 (Mastercard and VISA accepted).

BY MAIL- enclose a cheque or money order or complete the credit card details and payment details ($5000.00
maximum payment for credit card) then post it to ACT Architects Board, ACT Planning and Land Authority, GPO Box 1908, Canberra ACT 2601.

ACT ARCHITECTS BOARD ENQUIRIES - Please call (02)6207 6288, facsimile (02) 6207 6438.

Payment authority - for fax or mail payments only (see above)

Please charge the amount of $ 	 to the:	Mastercard	Visa   of:

Name of cardholder

Card number	Expiry date	/	/

Cardholder’s
signature	Date	/	/