ACT HERITAGE REGISTER
					AF2014-103
For ACT Heritage Use Only	
Date received		
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Date to Council		
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Accepted?		

ACT HERITAGE REGISTER—
REGISTER AMENDMENT APPLICATION
Heritage Act 2004, s24

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

This register amendment application form is used to amend the registration details of a place or object entered in the ACT Heritage Register. 

Any person can make an application to amend the registration details for a place or object. The registration details for which this form may be used to request amendment are the name, description (including boundary), and/or the statement of heritage significance including assessment against the heritage significance criteria for a registered place or object.

In making this application, you are asked to identify the requested amendments and provide supporting evidence. The fields in the application form will guide you with this.

Any mistakes or omissions in a heritage register entry do not require the use of this form and can be reported directly to ACT Heritage on 13 22 81 or by email to heritage@act.gov.au 

The ACT Heritage Council will notify you as soon as possible about its acceptance or dismissal of this application, and progress of associated processes and decisions. The Council may dismiss the application if the Council is satisfied on reasonable grounds that the application is frivolous, vexatious, misconceived, lacking in substance or not made honestly; or the Council has previously decided not to correct or change the register in the way proposed, and is satisfied that the application shows no substantial new reasons for correction or change. 

No fee is payable for making an application for a register amendment. 

DO YOU REQUIRE MORE INFORMATION OR NEED HELP?
If you need help completing this form, contact ACT Heritage on 13 22 81 or 
email heritage@act.gov.au. Incomplete or inadequate forms will be returned with feedback.

More information about the ACT Heritage Council, the Heritage Register and the heritage registration process
is available on the ACT Heritage website at www.environment.act.gov.au/heritage 
or by contacting ACT Heritage on 13 22 81 or by email at heritage@act.gov.au. 

LODGING YOUR FORM
Please send this form
o by mail to: The ACT Heritage Council, PO Box 158, Canberra  ACT 2601; 
o by hand to: ACT Heritage, Dame Pattie Menzies House, 16 Challis Street, Dickson ACT
o	 by email to: heritage@act.gov.au 

A register amendment application will not be accepted unless signed and dated.

01 DETAILS OF PLACE OR OBJECT

Place 		Object 

Type: 		natural 		Aboriginal 	 historic		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. 

02 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

		_______________________________________________________________________________
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 _______________________________

03 PROPOSED CORRECTION OR CHANGE
Please provide a brief statement of the proposed correction or change 

Does the proposed change affect the: 	name		description	        significance
__________________________________________________________________________________________
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04 REASONS FOR THE PROPOSED CHANGE
Please explain why you think this change is necessary 
__________________________________________________________________________________________
__________________________________________________________________________________________
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__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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05 HERITAGE SIGNIFICANCE 
If your proposed change affects the statement of heritage significance for the place or object, or an assessment against the heritage significance criteria, please complete this section to further explain the requested change.

For each of the heritage significance criteria please indicate how well you would rate this place or object. Ratings against each are:

•	High = meets to a high degree: excellent example, 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 these criteria:

(a)	importance to the course or pattern of the ACTs cultural or natural history	High
Meets
Not Met / NA
	
(b)	has uncommon, rare or endangered aspects of the ACTs cultural or natural history	High
Meets
Not Met / NA
	
(c)	potential to yield information that will contribute to an understanding of the ACTs cultural or natural history	High
Meets
Not Met / NA
	
(d)	importance in demonstrating the principal characteristics of a class of cultural or natural places or objects	High
Meets
Not Met / NA
	
(e)	importance in exhibiting particular aesthetic characteristics valued by the ACT community or a cultural group in the ACT	High
Meets
Not Met / NA
	
(f)	importance in demonstrating a high degree of creative or technical achievement for a particular period	High
Meets
Not Met / NA
	
(g)	has a strong or special association with the ACT community or a cultural group within the ACT for social, cultural or spiritual reasons	High
Meets
Not Met / NA
	
(h)	has a special association with the life or work of a person, or people, important to the history of the ACT	High
Meets
Not Met / NA

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)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

How and why it is significant? (including an explanation for each criterion rated as High or Meets)
In addressing each of the significance criteria, you are encouraged to spend most time on the criteria that the place or object best meets. 

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

Provide any known details for the owner/s, unless   	 same as person requesting change or correction

Is the owner/s aware of the application? 	no 	yes 	some are (indicate which if multiple owners)

Does the owner/s support this application?    no 	   yes 	some do, attach letter/s of support if possible

Does the owner consent to your providing their personal information?   	 no	yes

If yes, fill in the information below. If no, proceed to the next section

Current owner:	____________________________________________________________________
Name (attach additional details if multiple owners)

Address:	____________________________________________________________________
Postal or Street Address State Postcode

Telephone:	____________________________________________________________________
Business Hours	After Hours	Mobile

		_____________________________________________________________________________
Email

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.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Key significant (or intrinsic) features: (e.g. interiors, exterior elements, archaeological, landscape or natural
features, for objects give number and dimension/s.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Current physical condition: (covering key features and attach photographs)
__________________________________________________________________________________________
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Imminent threats to its significance _____________________________________________________________
__________________________________________________________________________________________

Other heritage listings:
Statutory lists
National Heritage List			Commonwealth Heritage List
Non-statutory lists
	National Trust of Australia			Australian Institute of Architects
Other/s ________________________________________

Supporting Documentation: Please list any further documentation that will support this application,
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 ACT Heritage for blank
forms).

Author/s or Source	Title/Description	Date	

			

List all attachments enclosed:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

06 AUTHORISATION 

I wish to request that the registration details for this place or object be changed or corrected 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 understand that giving false or misleading information is a serious offence under the Criminal Code 2002.

07 PERSONAL INFORMATION DISCLOSURE STATEMENT

The personal information on this form is provided to the ACT Heritage Council and ACT Environment and Planning Directorate for the purpose of processing your application for amendment of the ACT Heritage Register. If you do not provide your contact details, the Heritage Council will not be able to process your application. EPD’s Information Privacy Policy contains information about how you may access or seek to correct your personal information held by EPD, and how you may complain about an alleged breach of the Territory Privacy Principles. The EPD Information Privacy Policy can be found at www.act.gov.au/epd/information_privacy.

       By ticking this box I give my consent for my name/organisation to be disclosed as the applicant for this register amendment.  

Signed: ______________________________

Date: _________________