Office Use Only
Date received __________
GIPA reference_________
Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
Please complete this form to apply for fomal access to government information under the
Government Information (Public Access) Act 2009 (GIPA Act).
1. Your Details
Name: ______________________________________________________________________
Organisation: ________________________________________________________________
Postal Address: ______________________________________________________________
___________________________________________________
Postcode: ________________
Contact Telephone: _______________________
Facsimile: __________________________
Email: ______________________________________________________________________
2. Proof of Identity
Are you seeking access to your own personal information?
Yes / No
(circle one)
If yes, you must provide proof of identity in the form of a certified copy of any one of the following
documents:
Australia Passport Australian Drivers Licence Other proof of signature
(current) (with current address) & current address
3. Government Information
Please describe the information you are seeking access to in enough detail to allow it to be
identified. Avoid using phrases such as
“any and all”, “and/or” and
“including but not limited to” as this may make your application too broad or prevent us identifying the information.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
To minimise processing time and cost you may wish to limit the scope of your application by
clarifying that you are only seeking information contained in certain records held by the
Department, such as:
By Date: _____________________________________________________________________
(eg., only records created after X date)
By Type: ____________________________________________________________________
(eg., only external correspondence sent & received by the department, specific documents)
By Sector: ___________________________________________________________________
(If unsure please check our home page at
www.industry.nsw.gov.au)
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4. Public Interest
Please provide some reasons why you think this information should be released. We will
consider these when making our decision.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
5. Releasing your name during third party consultations
If information is sought that is of a kind that would require consultation with a third party (as
required under the GIPA Act), your name may be disclosed to the third party.
Do you object to this?
(tick one of the following boxes) Yes
No
6. Application Fee
All applications must be accompanied by payment of a
$30 application fee.
Payment can be made by cheque or money order and should be made payable to:
NSW Department of Industry
7. Discount in processing charges
You may be asked to pay a charge for processing the application ($30 / hour). Some applicants
may be entitled to a 50% reduction in their processing charges. If you wish to apply for a
discount, please indicate the reason:
Financial hardship – please attach supporting documentation (eg a pension or Centrelink
card, proof the organisation holds a charitable fundraising authority).
AND / OR Special benefit to the public – please specify why below:
.........................................................................................................................................................
........................................................................................................................................................................
8. 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 may be recorded in the agency’s ‘disclosure log’. This is
published on the agency’s website.
Do you object to this?
Yes / No (circle one)
9. Lodgement of form
Please post completed forms to:
Governance & Information Requests Unit Level 7 Legal Branch
NSW Department of Industry
PO Box K348
Haymarket NSW 1240
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Document Outline
