<p> Application form Heritage</p><p>Request for a certified copy of entry</p><p>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. </p><p>1. Applicant details</p><p>APPLICANT NAME YOUR REFERENCE</p><p>POSTAL ADDRESS</p><p>CONTACT PERSON TELEPHONE</p><p>EMAIL ADDRESS</p><p>2. Place Details</p><p>NAME OF QUEENSLAND HERITAGE PLACE QUEENSLAND HERITAGE REGISTER NO. </p><p>STREET ADDRESS (include street number and corner street if applicable)</p><p>SUBURB / TOWN</p><p>LOCAL GOVERNMENT AREA</p><p>LOTS ON PLAN/S</p><p>PARISH COUNTY</p><p>Application form Request for certified copy of entry</p><p>3. Preferred way to receive a certified copy of entry</p><p>Return via email (response time up to 5 working days) </p><p>Return via mail (response time up to 7 working days)</p><p>Note: Times are based on an accurately completed form and payment of the correct fee. </p><p>4. Lodgement and fees</p><p> 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.</p><p>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)</p><p>Further information </p><p> call (07) 3330 5859 or email [email protected]</p><p> visit www.qld.gov.au/environment/land/heritage/ for heritage information  search fees and services at www.ehp.qld.gov.au for fee information</p><p>Page 2 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</p><p>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.</p><p>DAYTIME TELEPHONE NUMBER: ( ) </p><p>MASTERCARD TYPE OF CREDIT CARD: VISA</p><p>NUMBER ON FRONT OF CARD: / / / </p><p>VALID FROM: / 20 VALID TO: / 20 </p><p>NAME AS IT APPEARS ON CARD: </p><p>CARDHOLDER’S SIGNATURE:</p><p>PRODUCTS/SERVICES REQUESTED Certified copy of entry</p><p>QUANTITY </p><p>COST PER ITEM</p><p>Refer to website www.ehp.qld.gov.au for current fees </p><p>TOTAL COST: $ </p><p>Office Use Only</p><p>DETAILS OF STAFF MEMBER ACCEPTING NAME: ______REQUEST – PRINT NAME AND EXTENSION PLEASE. EXTENSION: ______</p><p>RECEIPT NUMBER: ______DATE: ______AMOUNT $: ______</p><p>Page 3 of 3 • 150813 Department of Environment and Heritage Protection www.ehp.qld.gov.au ABN 46 640 294 485</p>