Owner’s Name: Address: Email: Telephone/Mobile Number: Charity Number: (if applicable) Date: Tax Reference Number: 2. Applicant Details (if not Name: Address: Telephone/Mobile Number: Email: Charity Number: (if applicable) Tax reference Number: Date: Please indicate if the consent of the owner been obtained to apply under this scheme and attach consent to this Form. 3. Structure Details Name: Address: Year of construction: (if known) Existing use: Proposed use: (if different) 4. Classification Yes or No If yes: registration number (a) protected under the RMP: National Monuments Acts? Is the structure: (b) a protected RPS: structure?
Owner’s Name: Address: Telephone/Mobile Number: Email: Charity Number: (if applicable) Tax Reference Number: Date: 2. Applicant Details (if not Name: Address: Telephone/Mobile Number: Email: Charity Number: (if applicable) Tax reference Number: Date: Please indicate if the consent of the owner been obtained to apply under this scheme and attach consent to this Form. 3. Structure Details Name: Year of construction: (if known) Address: Existing use: Proposed use: (if different) 4. Classification Yes or No If yes: registration number Is the structure: (a) protected under the National Monuments Acts? RMP: (b) a protected structure? RPS:
BHIS_2017_Circular_Jan_2017.docx