IMPORTANT NOTE THIS NOTIFICATION MUST BE PROVIDED TO THE

Contact details of the person giving notice

First name:

Surname:

Town/City:

State:

Street number:

Street name:

Mobile:

Postcode:

Post office box:

Telephone (Business hours): ( )

Facsimile: ( )

Email:

Additional details if the relics are held by a business, association or government entity

Name:

ABN:

Details of Historic Shipwreck with which the relic is believed to be associated (if known)

Name of Historic Shipwreck:

Register of Historic Shipwrecks ID number:

Details if the possession, custody or control is the result of a transfer of possession

Is the possession, custody or control a result of a transfer of possession?

Yes No

If Yes, please provide permit number for transfer:

Date of transfer:

Description of relic (Include photographs or digital images of the relic where possible)

Registered number

(If registered)

Type of object

(coin, anchor, bottle etc)

Features

(markings, writing, design etc)

Dimensions

(length, width, height, weight)

L cm

W cm

H cm

W g

L cm

W cm

H cm

W g

L cm

W cm

H cm

W g

Please answer the following questions (attach additional information if space is insufficient)

Where was the relic found or acquired?

How is the relic stored?

What is the condition of the relic?

Name (block letters):

Date:

Signature: