Architects Act 2004 – s92 - Change of address details\ replacement registration card ACT architects registration
1. Details (Please nominate an option)

  A4 	

Change of address details	Replacement Registration Card (Please provide a certified copy of photo identification)

Reason for replacement:	Lost card	Card destroyed	Card stolen	Other ...................................................................

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

Organisation

Title

Given names

Residential address

Postal address

Surname

ACN

Date of bir th	/	/

State/Territory	Postcode

State/Territory	Postcode

Business address

State/Territory	Postcode

Home phone	Business  phone

Mobile phone	Facsimile

Email

Contact person

Registration number

3. Declaration

I, (print name) .................................................................................................................................................................... declare that all the information
contained in,  and attached to this form is complete, accurate and true to the best of my knowledge.
I understand that there are severe penalties for providing false or misleading information.

Signature	Date	/	/

Office use only

Fees

App fee. Lic. fee. Other

Date received
/	/

Receipt no. Licence  no. Receiving officer

4. Fees and charges for financial year 2010-2011

Replacement registration card fee $38.30
Please provide your name and address on the back of the cheque and make payable to the ‘Receiver of Public Monies’.
Present this form:
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 Customer Service Centre, 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 and payment details ($5000.00 maximum payment for credit card) then fax it to ACT Planning and Land Authority Customer Service Centre on fax number (02) 6207 1925
(Mastercard and Visa accepted).

Please charge the amount of $ .............................................    to the:	Mastercard	Visa of: Name of cardholder

Card number	Expiry date	/	/

Cardholder’s
signature	Date	/	/

BY MAIL	enclose a cheque or money order or complete the credit card 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.
ENQUIRIES	Please call (02) 6207 6288, facsimile (02) 6207 6438.