GOVERNMENT INFORMATION
(PUBLIC ACCESS) ACT 2009
FORMAL ACCESS
APPLICATION
Please complete this form to apply for information held by Council under the
Government Information
(Public Access) Act 2009 (GIPA Act). If you need help in filling out this form, please contact the Right
to Information Officer on 9840 9840, or visit our website at www.cumberland.nsw.gov.au.
1.
Your Details
Title: Mr / Mrs / Ms
Surname: .........................................................................................................
Other names: .......................................................................................................................................................
Postal address: .....................................................................................................................................................
...............................................................................................................................................................................
Contact number: .................................................................... Facsimile: .........................................................
Email: ..................................................................................................................................................................
Are you seeking personal information? Yes / No
(circle one)
Proof of Identity: .................................................................................................................................................
2.
Government Information
Please describe the type of information you would like access to in enough detail for us to identify it:
...............................................................................................................................................................................
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Office Use Only:
Date application received: .................................................................................... TRIM No: .................................................................
Received by (Officer): ...............................................................................................................................................................................
2
3.
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)
...............................................................................................................................................................................
4.
Application Fee
I attach payment of the $30 application fee by cash / cheque / money order
(circle one).
(Note: Please DO NOT send cash by post)
5.
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
(circle one)
Council endeavours to expedite the release of the requested information, as soon as possible within 20
working days after receipt of the application. Photocopying charges may apply if copies of the relevant
information is requested.
PRIVACY NOTE: Council will collect and hold the personal information contained in this application for
the purpose of processing the application. The intended recipients of the personal information are officers
within Council. The supply of personal information by you is voluntary, however if you cannot provide, or
do not wish to provide the information sought, Council may be unable to process your application.
You may make an application for access or amendments to your personal information held by Council under
the
Privacy and Personal Information Protection Act 1998 (
PPIP Act) or the
Government Information
(Public Access) Act 2009 (
GIPA Act). You may also make a request that Council suppress your personal
information from a public register. Council will consider any such application in accordance with the PPIP
Act.
Information provided to Council in correspondence, submissions or requests, including your personal
information, may be made publicly available, including on Council's website, under the GIPA Act. Please
notify us if you object to the disclosure of your personal information.
Please email, fax, post or lodge this form at:
Cumberland City Council
16 Memorial Avenue
Merrylands NSW 2160
PO Box 42
Merrylands NSW 2160
Fax: 9840 9734
Email: xxxxxxx@xxxxxxxxxx.xxx.xxx.xx