Place nomination form - local heritage

Your details

Name

Address

Suburb

Postcode

Phone number

Email address

Has the owner or occupier been consulted?

YesNo

Signature

Date

Place details

Please provide as much detail as possible on the location, area or boundary.

Name of place

Any former or other names

Address

Lot/location

Diagram/plan/title details (if known)

History and type of place

Physical description

Describe the place and its setting as clearly as possible. Attach photos if you wish.

Upload photo

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

What parts of the place are original?

Do you know of any major changes to the place and when?

Construction materials

If you are nominating a building, what is it made of?

Are there any features in the garden or landscape?

If you are nominating a place that's not a building, what are its features?

Owner or occupier details

If known

Name

Address

Suburb

Postcode

Phone number

Is the place occupied?

YesNo

Documents

Please upload any relevant documents

Upload documents

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Place nomination form - local heritage

Your details

Place details

History and type of place

Physical description

Construction materials

Owner or occupier details

Documents

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