Form: Request for a Certified Copy of Entry

Application form Heritage

Request for a certified copy of entry

Use this form to request a certified copy of the entry for a place on the Queensland Heritage Register. Use a new form for each Queensland Heritage Place.

1. Applicant details

APPLICANT NAME YOUR REFERENCE

POSTAL ADDRESS

CONTACT PERSON TELEPHONE

EMAIL ADDRESS

2. Place Details

NAME OF QUEENSLAND HERITAGE PLACE QUEENSLAND HERITAGE REGISTER NO.

STREET ADDRESS (include street number and corner street if applicable)

SUBURB / TOWN

LOCAL GOVERNMENT AREA

LOTS ON PLAN/S

PARISH COUNTY

Application form Request for certified copy of entry

3. Preferred way to receive a certified copy of entry

Return via email (response time up to 5 working days)

Return via mail (response time up to 7 working days)

Note: Times are based on an accurately completed form and payment of the correct fee.

4. Lodgement and fees

 A fee applies to each Queensland Heritage Place searched for. Search fees and services at WWW.EHP.QLD.GOV.AU/ FOR FEE INFORMATION.  Correct payment must accompany this application form.  If paying by credit card, please complete the attached credit card payment option form. Once completed, this form can only be returned via fax to (07) 3330 5996.  Cheques should be made payable to the Department of Environment and Heritage Protection.  Please note urgent requests cannot be accommodated.

Send one copy of the completed form and payment to: Mail: OR Deliver: Heritage Branch Heritage Branch GPO Box 2454 Department of Environment and Heritage Protection Brisbane Level 3 Queensland 4001 400 George St BRISBANE (Business hours Mon – Fri)

Further information

 call (07) 3330 5859 or email [email protected]

 visit www.qld.gov.au/environment/land/heritage/ for heritage information  search fees and services at www.ehp.qld.gov.au for fee information

of 3 • 150813 Department of Environment and Heritage Protection www.ehp.qld.gov.au ABN 46 640 294 485 Application form Request for certified copy of entry Credit card payment option

If making payment by credit card complete the payment option form below and fax it along with a completed application form to (07) 3330 5996.

DAYTIME TELEPHONE NUMBER: ( )

MASTERCARD TYPE OF CREDIT CARD: VISA

NUMBER ON FRONT OF CARD: / / /

VALID FROM: / 20 VALID TO: / 20

NAME AS IT APPEARS ON CARD:

CARDHOLDER’S SIGNATURE:

PRODUCTS/SERVICES REQUESTED Certified copy of entry

QUANTITY

COST PER ITEM

Refer to website www.ehp.qld.gov.au for current fees

TOTAL COST: $

Office Use Only

DETAILS OF STAFF MEMBER ACCEPTING NAME: ______REQUEST – PRINT NAME AND EXTENSION PLEASE. EXTENSION: ______

RECEIPT NUMBER: ______DATE: ______AMOUNT $: ______

of 3 • 150813 Department of Environment and Heritage Protection www.ehp.qld.gov.au ABN 46 640 294 485