APPLICATION FOR ACCESS TO DOCUMENTS
Under Western Australian Freedom of Information Act 1992, Section 12
99 Shepperton Road
Locked Bag 437
Victoria Park WA 6100
Victoria Park WA 6979
Phone: (08) 9311 8111
xxxxx@xxxxxxx.xx.xxx.xx
Facsimile: (08) 9311 8181
www.victoriapark.wa.gov.au
Instructions: Please print using dark pen (black preferably) in the spaces provided.
1. APPLICANT DETAILS
Surname
Given Names
Australian Postal
Address
Post Code
Telephone
Mobile
Email
Name of
Organisation/Business
If you are acting on behalf of another person/organisation, written authorisation from this
person/organisation wil be required.*
2. REQUEST DETAILS
Please indicate whether documents are:
Personal Non Personal ($30 application fee applies)
(Please tick appropriate box)
Personal - Information about yourself, eg. details of employment, material in personal records.
Non Personal - Information you are seeking is not directly about you.
Please provide as much information as possible to identify the documents i.e location, subject matter.
Please specify actual documents rather than entire files. Your reason for access (optional) may assist
locating documents.
I am applying for access to document(s) concerning:
Continued:
Specify Dates From
To
3. FORM OF ACCESS
Please indicate form of access required:
Inspection Printed Copy Electronic Copy
(Please tick appropriate box)
4. FEES AND CHARGES
Attached is a cheque/cash/money order/credit card payment for the amount of $30.00 to cover the
application fee.
I understand that before I obtain access to documents I may be required to pay processing charges in
respect of this application and that I wil be supplied with a statement of charges, if applicable.
I declare that all of the details set out above are true and correct.
Signature
Date
OFFICE USE ONLY
FOI File Reference
Received On
Deadline for response
*
Proof of Identity (if applicable)
Type
Sighted By
Print Name
Signature
(Officer)
