ACT HERITAGE REGISTER
					AF2015-147
For ACT Heritage Use Only	
Date received		
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ACT HERITAGE REGISTER—
Request for approval to publish restricted information
Heritage Act 2004, s56
 
This form may be used to request approval to publish restricted information under s.56 of the Heritage Act 2004 (the Act). Under s.54 of the Act, the ACT Heritage Council (the 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.

Under s.56(1) the Council may approve the publication of restricted information about a place or object if satisfied, on reasonable grounds, that the publication will not have a substantial adverse effect on the heritage significance of the place or object.

If approval to publish restricted information is granted by the Council in accordance with this application, the Council may impose conditions including, but not limited to the following:
1.	Publication is restricted to the information and nature as stated above; and
2.	The information is not to be made available for the general public or an audience broader than that described above.

A fee is not required for lodgement of this form. 

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.

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. RESTRICTED INFORMATION PROPOSED TO BE PUBLISHED

Do you already have access to the restricted information proposed to be published?
	Yes				No

If no:
What restricted information do you require:

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

	_______________________________________________________________

04. REASONS FOR SEEKING TO PUBLISH RESTRICTED INFORMATION 

	For research or study purposes, including student assignments and theses
	For reporting purposes in relation to land investigation
	Formally, in the public realm
	Other – please provide details

	________________________________________________________________

	________________________________________________________________

05. NATURE OF PUBLICATION

State the nature of the publication (including proposed date of publication)

___________________________________________________________________

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

___________________________________________________________________

___________________________________________________________________

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

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Are you publishing the information yourself?  	
Yes		No

If no, who is publishing the information?

	_______________________________________________________________

	_______________________________________________________________

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.

By signing this form, you agree that you are requesting the above information in accordance with the Heritage Act 2004, and that the information provided here is accurate to the best of your knowledge.

By signing this form, you further agree that you will not publish restricted information except in accordance with any approval given by the ACT Heritage Council, including any conditions that may be imposed.

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: _________________