Government Information (Public Access) Act 2009
FORMAL APPLICATION
In accordance with the Government Information (Public Access) Act 2009 ("GIPA") Part
4 Division 1 Section 41 (1), formal access applications
must comply with the following
requirements:
(a) It must be in writing sent to or lodged at an office of the agency concerned,
(b) It must clearly indicate that it is an access application made under this Act,
(c) It must be accompanied by a fee of $30,
(d) It must state a postal address in Australia as the address for correspondence in
connection with the application,
(e) It must include such information as is reasonably necessary to enable the
government information applied for to be identified.
If you require assistance in completing this form, please contact Customer Services on
(02) 4325 8222 or visit our website at
www.gosford.nsw.gov.au .
1.
Your details
Surname:……………………………………………………………………………………
First Name(s): ……………………………………………………………………………..
Title: Mr / Mrs / Ms / Other………………………………………………………………...
Email:………………………………………………………………………………………..
Postal Address:……………………………………………………………………………
Suburb:…………………………………..
State:………………
Postcode:……………..
Telephone number(s):…………………………………………………………………….
Payment hotkey: 457 03/06/14
2. Details of Application
Please describe the information you would like access to in enough details to
assist us with identification:
Note: If you are not specific about the information you require Council may refuse to
process your application; however Council will endeavour to assist in defining the request
to a more manageable one.
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Date Range of documents required:…./…./…. to …./…./….
Do the documents contain information about your personal information?
[ ] Yes [ ] No
Personal Information means information or an opinion (including information or
an opinion forming part of a database and whether or not recorded in a material
form) about an individual (whether living or deceased) whose identity is apparent or
can be reasonably be ascertained from the information or opinion.
3. Document Provision
In the interests of the environment and as is consistent with Council's Environment
Policy, this information wil be provided electronically, therefore please ensure you
have provided an email address. An alternative method of provision may be
considered.
4. 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 Council's
disclosure log. The log wil contain what information was requested, the date of
request, the number of pages released and how other members of the public can
access it. No personal details will be provided on the disclosure log.
Payment hotkey: 457 03/06/14
5. Fees and Charges
I attach cheque / money order / cash to the amount of $30 required with the
application to cover the application fee.
(Please do not send cash through the
mail.)
I understand that I may be required to pay processing charges in respect of this
request and that I wil be supplied with a statement of charges if appropriate.
Note:
In certain cases a 50% reduction in processing charges may apply. If you
consider you are entitled to a reduction, please provide copies of
supporting documents with this form.
I am requesting a reduction in processing charges: [ ] Yes [ ] No
Applicant's signature:………………………………………Date:………………………...
Send applications to:
Chief Executive Officer
PO Box 21
Gosford NSW 2250
Payment hotkey: 457 03/06/14
