Government Information (Public Access) Act 2009
ACCESS APPLICATION
Please complete this form to apply for formal access to government information under the
Government Information (Public Access) Act 2009 (the GIPA Act). For further information, please
contact the Governance and Integrated Planning Division on 9369 8000 or visit our website at
www.waverley.nsw.gov.au/your_council/Access_Council_Information.
APPLICANT
Title
Given Name/s
Family Name
Organisation
Postal Address
Postcode
Daytime telephone Facsimile
Email Address
If you are acting on someone’s behalf please provide that person’s:
Given Name/s
Family Name
Please attach proof of your authorisation to act on the person’s behalf, such as legal documentation in support of your
authority (for example: a client agreement if you are a solicitor) or written authorisation from the person concerned.
PROOF OF IDENTITY
Only required when an applicant is requesting information on their own behalf.
When seeking access to personal information, an applicant must provide proof of identity in the form of a certified
copy of any one of the following documents:
Australian driver’s licence (with photograph, Current Australian Passport
Other proof of signature
signature
and
current
address)
and current address
GOVERNMENT INFORMATION
Please describe the information you would like to access in enough detail to allow us to identify it.
Note: If you do not give enough details about the information, Council may refuse to process your application.
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Are you seeking personal information?
Yes
No
Third Party Consultation – Council may need to consult with other parties about the release of the information that
you have requested. Do you object to your name being released to these parties?
No, I have no objection to the release of my name
Yes, I object to the release of my name
FORM OF ACCESS
How do you wish to access the information?
Inspect the document(s)
A copy of the document(s)
Access in another way (please specify)
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’. This is published on Council’s website.
Do you object to this?
Yes
No
APPLICATION FEE
I attach payment of the
$30 application fee by
Cash (only at Customer service Centre)
(
Note: please do
NOT send cash by post)
Cheque
Money order
If you are given access to the information sought, 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) AND / OR
Special benefit to the public – please specify why below:
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PRIVACY
In making this application, you are providing personal information such as name and contact details. This
information will be used for the purpose of assessing your application and ensuring we are able to remain in
contact with you regarding the status of your application. Your personal information will be accessed by persons
who have been authorised to do so, including the decision maker for your application. Your personal information
will be handled in accordance with the Privacy and Personal Information Act, 1998.
SIGNATURE
1.
I declare that the information given on this application form is true and correct.
2.
I understand that I must seek the Copyright Owner’s consent in order to use any part of a copyright
document for any other purpose.
Applicant’s name
Applicant’s signature
Date
HOW TO LODGE THIS APPLICATION
In person:
Waverley Council Customer Service Centre
Mail:
Governance & Integrated Planning
55
Spring
Street Waverley
Council
Bondi
Junction
PO
Box
9
8.30am – 5.00pm Monday to Friday
Bondi Junction NSW 1355
OFFICE USE ONLY
Costcode: FREDOM
Received by
Date received
Information about the GIPA Act is available by calling the Information and Privacy Commission on
freecall 1800 472 679 or at its website www.ipc.nsw.gov.au