ACCESS APPLICATION FORM
Government Information (Public Access) Act 2009
APPLICANT DETAILS
Title
First name
Surname
Company name
ABN
Postal address
State
Postcode
Contact no
Email address
I agree to receive all correspondence related to this application at the above email address
Yes
No
PROOF OF IDENTITY
If you are seeking access to personal information (including your own), please
attach a certified copy of one of the following
to your application.
Australian Drivers Licence
Australian Passport
Letter of Authority (if acting on
behalf of someone else)
Government issued ID card
Other. Please specify
APPLICATION FEE
The application fee is $30. This fee must be paid to successfully lodge an application.
EFT Transfer
Bank Account:
Fire and Rescue NSW Operating Account
BSB: 032 001
Account number: 205223
If paying by EFT you
must include your last name and “GIPA” in the payment reference field,
and attach proof of payment to this application form
Cheque / Money Order
Cheques/Money orders are to be made payable to
Fire and Rescue NSW
Cash
Cash can only be paid in person at
Headquarters, 1 Amarina Ave, Greenacre NSW 2190
GOVERNMENT INFORMATION
Please describe in detail the information you would like to access to allow the record(s) to be identified. If you do not
provide sufficient information your application may be deemed invalid, or we may not be able to find the information you are
seeking. Attach to this application any relevant documents if there is not enough space.
Date range (if applicable)
From
To
=
GIPA Acess Application Form
Date of Effect: 22 January 2021
FIRE AND RESCUE NSW
ABN 12 593 473 110
www.fire.nsw.gov.au
Office of the Commissioner
1 Amarina Ave,
T (02) 9269 6447
Legal & Regulatory Services
Greenacre NSW 2190
xxxx@xxxx.xxx.xxx.xx
Sensitive
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FORM OF ACCESS
How do you wish to access the information?
A copy of the document(s)
Inspect the document(s)
Data on a spreadsheet
Other. Please specify
PROCESSING CHARGES
You may be asked to pay a charge for processing the application ($30 per hour).
Some applicants may be entitled to a 50% reduction of processing charges on the grounds of personal hardship or because
the information sought is of special interest to the public. If you wish to apply for a discount on the processing charges, please
indicate the reason:
Financial hardship. Please attach supporting documentation e.g. Health Card, Pension or Centrelink card
Special benefit to the public. Please specify why:
CONSULTATION
The agency may be required to consult with third parties before deciding the application. For the purposes of
consultation, please indicate if the agency can disclose the following information about you to third parties:
Your name and/or company name
Yes
No
Your reason for making this application
Yes
No
DISCLOSURE LOG
If the information sought is released to you and would be of interest to other members of the public, details about your
application (excluding your personal information) may be recorded in the agency’s ‘disclosure log’. This is published on the
agency’s website.
Do you object to information released being included in the Disclosure Log?
Yes
No
If you do object, please specify why:
PRIVACY STATEMENT
Fire and Rescue NSW is subject to
the Privacy and Personal Information Protection Act 1998 and th
e Health Records and
Information Privacy Act 2002.
Your personal information is being collected to process your application for information pursuant to Part 4, Division 1 of the
Government Information (Public Access) Act 2009. The provision of personal information is voluntary, however if you do not
provide it we may not be able to process your application. Fire and Rescue NSW may use your personal information for the
purposes of processing your application within the agency. Fire and Rescue NSW will not disclose your personal information
without your consent unless authorised by law. Your personal information will be held by Fire and Rescue NSW.
Generally you have the right to access and correct the information if you believe that it is incorrect. If you wish to do so,
please contact the Privacy Officer by email at
xxxxxxxxxxxxxx@xxxx.xxx.xxx.xx or call (02) 9269 6447.
Signature
Date
Applications can be lodged using the following methods:
Post by mail
Deliver in person
Email
Fire and Rescue NSW
Fire and Rescue NSW Headquarters
Locked Bag 12
1 Amarina Ave
xxxx@xxxx.xxx.xxx.xx
GREENACRE NSW 2190
GREENACRE NSW 2190
GIPA Acess Application Form
Date of Effect: 22 January 2021
FIRE AND RESCUE NSW
ABN 12 593 473 110
www.fire.nsw.gov.au
Office of the Commissioner
1 Amarina Ave,
T (02) 9269 6447
Legal & Regulatory Services
Greenacre NSW 2190
xxxx@xxxx.xxx.xxx.xx
Sensitive
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