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 (
GIPA Act). If you need help in filling out this form, please contact
the Right to Information Officer on 02 6578 7224 or visit our website at
www.singleton.nsw.gov.au
1.
Your details
Surname:
............................................................................................
Title: Mr / Ms
Other names:
.....................................................................................................................
Postal address:
...................................................................................
Postcode: .............
Day-time telephone: ............................................
Facsimile: .....................................................
Email:
.....................................................................................................................
The questions below are optional and the information will only be used for the purposes of providing better service.
Place of birth:
…………………………………..
Main language spoken: ……………………..
Aboriginal or Torres Strait Islander:
Yes / No (circle one)
Do you have special needs for assistance with this application: ................................................
………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………..
I agree to receive correspondence at the above email address.
2.
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
Current Australian passport
with photograph, signature and current address
Other proof of signature and current address details
3.
Government information
Please describe the information you would like to access in enough detail to allow us to identify it.
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Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
Note: If you do not give enough details about the information, the agency may refuse to process your
application.
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Are you seeking personal information?
Yes / No (circle one)
4.
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) ......................................................................................
..........................................................................................................................................................
5.
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)
6.
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)
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).
General information about the GIPA Act is available by calling the Information and Privacy Commission on
1800 472 679 or visti the IPC’s website: www.ipc.nsw.gov.au
Office use only
Date application received: ................................................................................
File reference: ...................................................................................................
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Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
AND / OR
Special benefit to the public – please specify why below:
..........................................................................................................................................................
..........................................................................................................................................................
Applicant’s signature: .........................................................................
Date: .................................................................................................
Please post this form or lodge it at:
Singleton Council
PO Box 314
Singleton, 2330
Queen Street
Singleton, 2330
xxx@xxxxxxxxx.xxx.xxx.xx
General information about the GIPA Act is available by calling the Information and Privacy Commission on
1800 472 679 or visti the IPC’s website: www.ipc.nsw.gov.au
Office use only
Date application received: ................................................................................
File reference: ...................................................................................................
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