THE SURVEYORS BOARDof the

NORTHERN TERRITORY

GPO Box 1154DARWIN NT 0801

Telephone: (08) 8999 1826Facsimile: (08) 8999 1888

REGISTRATION OF PROFESSIONAL ASSESSMENT EXAMINATIONUNDER THE LICENSED SURVEYORS ACT 2013

REGISTRATION DETAILS

Agreement Between

Graduate Surveyor

Supervising Surveyor

Telephone

Email

I confirm I have met all requirements detailed in the Training Requirements for Graduate Surveyors Guideline

I have attached the Form 5 completed and signed by my Supervising Surveyor

I enclose the prescribed fee of $335

Agreement lodged by

Signature Date

FEE AND PAYMENT OPTIONSCash – Territory Business Centre

Cheque – payable to Territory Business CentreCredit card Visa MasterCard

Credit Card number

Expiry date

Name on card

I hereby authorise the Territory Business Centre to debit the above credit card for the amount of

$

Amount in words

Signature of card holder Date:

Contact phone number

Registration of Professional Assessment Examination________________________________________________________________________________

LODGEMENT OPTIONS

DarwinDarwin Corporate ParkGround Floor, Building 3631 Stuart Highway, BerrimahGPO Box 9800 Darwin NT 0801

t: (08) 8982 1700f: (08) 8982 1725Toll free: 1800 193 111e: territory.businesscentre@nt.gov.au

KatherineShop 1, Randazzo Building 18 Katherine TerraceKatherinePO Box 9800Katherine NT 0851

t: (08) 8973 8180f: (08) 8973 8188e: territory.businesscentre@nt.gov.au

Tennant CreekShop 2, Barkly HouseCnr Davidson and Paterson StreetsTennant CreekPO Box 9800Tennant Creek NT 0861

t: (08) 8962 4411f: (08) 8982 1725e: territory.businesscentre@nt.gov.au

Alice SpringsGround Floor, The Green Well Building50 Bath StreetAlice SpringsPO Box 9800Alice Springs NT 0871

t: (08) 8951 8524f: (08) 8951 8533e: territory.businesscentre@nt.gov.au