Full name: .................................................................................... D.O.B: ..........................................................
 
Residential Address: ...........................................................................................................................................

 …………………………………………………………………………………………………………………

Telephone (h):   ................................……..................    Mobile:   .....................................................................

Business Name: ……………………………………………………………………………………………….. 
 
Business Postal Address: ………………………………………………………………………………………

Tel (w)    ................................……....................   Fax: (w)    .............................................................................

Preferred Postal Address:             Home                                       Business    
 
Email Address: ………..………………………………………………………………………………………
 
State where first registered: ................................................................................................................................
 
Certificate of Competency No: ............................................................................................................................
 
Date registered: ................................................... Registration current to:  ........................................................
 
All states in which registered: .............................................................................................................................
 
Registration is current to: ....................................................................................................................................
 
Certificates of Competency No’s .........................................................................................................................

Registered/licensed to perform cadastral surveys: 	Yes  /  No 
 
Endorsed to consult to the public: 			Yes  /  No
 
Tertiary qualifications: ........................................................................................................................................

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

Are you the subject of investigation/disciplinary proceedings in any State?...................................................... 
(If yes, please attach full details)

 Has your registration been cancelled/suspended as a result of disciplinary action in any State? .....................
(If yes, please attach full details) 

Are you subject to any special conditions to practise in any State? ................................................................... 
(If yes, please attach full details) 

Are there any restrictions, or are you prohibited from practising as a surveyor, as a result of any criminal 

civil or disciplinary proceedings in any State?..................................................................................................
(If yes, please attach full details) 

 
 
I hereby give consent to the making of inquiries and the exchange of information with the Surveyors Board or authorised person of any State or Territory regarding my activities in surveying or any other matter relevant to the notice. 
 
Attached is a Letter of Accreditation from the Surveyors Board of (State): ......................................................

Signed: ..................................................................................................       Date: ..............…………………… 

The signature below is that which I shall use in signing plans, survey reports and other documents as a surveyor registered with the Surveyor-General of the Australian Capital Territory.

Full Name:...................................................................................................................... 
 
Address........................................................................................................................... 
 
………............................................................................................................................. 
 
Telephone: (H)..................................................(W)........................................................ 

Specimen Signature - Please use dense black ink. 

	

 

Date:      /      /            

___________________________________________________________________________________

OFFICE USE ONLY

Certificate of Competency No: ..................................... Dated:      /     /           
 
Letter of Accreditation from: ............................................. No ....................... 
 
Date of ACT Registration:         /      /     

Registration Number: .......................................... 

 ………................................................... 
 Registrar