Heritage Removal of a place from the Queensland Heritage Register Use this form to make an application to have all or part of a State Heritage Place considered for removal from the Queensland Heritage Register under the Queensland Heritage Act 1992. Before completing this application form: read the Application Guide: Removing a State Heritage Place from the Queensland Heritage Register available at call 13 QGOV (13 74 68) and discuss this application with the Applications Co-ordinator, Heritage Branch Applicant details APPLICANT NAME/S TITLE applicable) ORGANISATION NAME (if POSTAL ADDRESS POSTCODE EMAIL ADDRESS hours) MOBILE TELEPHONE (business hours) EMAIL TELEPHONE Applicant consent Ticking YES in the box below means you give consent to the department to publicly disclose your name with this application. At no time (whether you tick YES or NO) will your personal contact details be made public during processing and assessment of this application. The department removes contact details (i.e. address, email and telephone numbers) from all copies of the application except those provided to the Queensland Heritage Council. Applicant consents to personal information being released Yes No APPLICANT’S SIGNATURE
Heritage Removal of a place from the Queensland Heritage Register Use this form to make an application to have all or part of a State Heritage Place considered for removal from the Queensland Heritage Register under the Queensland Heritage Act 1992. Before completing this application form: read the Application Guide: Removing a State Heritage Place from the Queensland Heritage Register available at call 13 QGOV (13 74 68) and discuss this application with the Applications Co-ordinator, Heritage Branch Applicant details APPLICANT NAME/S TITLE ORGANISATION NAME (if applicable) POSTAL ADDRESS POSTCODE EMAIL ADDRESS TELEPHONE (business hours) MOBILE TELEPHONE hours) EMAIL Applicant consent Ticking YES in the box below means you give consent to the department to publicly disclose your name with this application. At no time (whether you tick YES or NO) will your personal contact details be made public during processing and assessment of this application. The department removes contact details (i.e. address, email and telephone numbers) from all copies of the application except those provided to the Queensland Heritage Council. Applicant consents to personal information being released Yes No APPLICANT’S SIGNATURE
app-form-remove-place-qld-her-reg.docx