ACT HERITAGE REGISTER
					AF2014-106
For ACT Heritage Use Only	
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ACT HERITAGE REGISTER—
Request for approval to publish restricted information
Heritage Act 2004, s56
 
The ACT Heritage Register contains details of places and objects of significance to the ACT.

This form may be used to request approval to publish restricted information under the Heritage Act 2004. In some instances the ACT Heritage Council can declare particular information to be restricted if satisfied, on reasonable grounds, that public disclosure of the information would be likely to have a substantial adverse effect on the heritage significance of a place or object, or to an Aboriginal place or object. It is an offence to knowingly publish this information without formal approval.

The ACT Heritage Council is under no obligation to approve the publishing of restricted information and may not do so if it considers it possible that by doing so there may be a substantial adverse effect on the heritage significance of the place or object, or on the Aboriginal place or object.

A fee is payable on receipt of this form. Additional charges may apply where the request relates to a large area. A schedule of fees is available on the ACT Heritage website at www.environment.act.gov.au/heritage. 

This form is not required for access to and/or to publish restricted information if the request: 
a)	is made by a person with a traditional affiliation with the place or object AND 
b)	the information: 
•	will be given to another Aboriginal person OR 
•	will be used for the purpose of education about Aboriginal tradition OR 
•	is necessary and reasonable to avoid an imminent risk of damage to, or destruction of, an Aboriginal place or object.

In these instances, this form is optional and no fees apply.

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 

01 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

02 DETAILS OF PLACE OR OBJECT 
What place or object does this application relate to?

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)

03 REASONS FOR SEEKING TO PUBLISH RESTRICTED INFORMATION 
Traditional affiliation
Do you have a traditional (Aboriginal) affiliation with the place or object?
	Yes		No

What is your purpose in seeking to publish the restricted information?
	To give to another Aboriginal person
	To educate about Aboriginal tradition
	To avoid an imminent risk of damage to, or destruction of, an Aboriginal place or object
Other

Are you publishing the information yourself?  	
Yes		No

If no, who is publishing the information?

______________________________________________________________________

Other circumstances:
Please outline your reasons for seeking access to this information:

______________________________________________________________________

______________________________________________________________________

What details do you require:

	 Restricted location details
	 Restricted details of site name/type
	 The restricted Heritage Register entry (ie – all restricted details)
	 Other _______________________________________________________________

Details of publication

State the reasons for publication
___________________________________________________________________

___________________________________________________________________

State the nature of the publication (type of publication method; proposed date)

___________________________________________________________________

___________________________________________________________________

State the person, people or kind of people to whom it would be directed

___________________________________________________________________

___________________________________________________________________

Confirmation that the publication will not have a substantial adverse effect on the heritage significance of the place or object:

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

04. 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 approval to publish restricted information. 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.
‘I am applying for restricted Information from the ACT Heritage Register in accordance with the Heritage Act 2004. The information provided here is accurate to the best of my knowledge.’

I understand that giving false or misleading information is a serious offence under the Criminal Code 2002.

I have read and understand the provisions of Part 9 of the Heritage Act 2004.

Signed: ______________________________    Date: _________________