DoE File Reference GIPA-
Government Information (Public Access) Act 2009 – GIPA Act
ACCESS APPLICATION
Before you fill in this form please read the Department’s agency information guide at http://www.dec.nsw.gov.au/about-
us/information-access and look to see whether the information you want is already available on our website. If in doubt,
contact our Information Access Unit and ask them if the information is already available or can be made available without
a formal access application under the GIPA Act.
Applicant details
Family name:
................................................................
Title: Mr / Ms / other ……....…
Other names:
...........................................................................................................................
Postal address:
................................................................................... ........................................
(compulsory)
...................................................................................
Postcode:......................
Day-time telephone: .........................................
M: ……………………. ........
Fax:………………..........
Email (optional):
........................................................................................................... ...............
I agree to the release of my name to any other (third) parties the department may need to consult as part of
my application. I understand that not agreeing could affect the outcome of my application.
I would like the following information from the Department:
………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………….
Note: For your application to be processed, you need to provide enough details for us to identify the information you want. For
help go to the website http://www.dec.nsw.gov.au or contact the Department’s Information Access Unit.
Please give the date range the information is to cover: ................................. to .................................
Optional: My reason for making this application:
………………………………………………………………………………………………………………………
Application Fee $30
Attach payment of the
$30 application fee by cheque or money order made out to:
Department of Education. Or make a Credit Card payment
(last page of this document contains credit
card payment form)
Form of access
We will provide you with a copy of the information released. If the information requested is more than 20
pages we will provide it on a computer disc, otherwise you will receive it by post/email. Please advise if
you require access in another way.
Proof of Identity required for personal information
For access to your own or your child’s personal information we need you to provide proof of identity. This
is to comply with privacy requirements. Please provide a copy of the following documents with your
application:
• Australian photo driver’s licence showing current address, or
• Current Australian passport, and current address details, or
• Other proof of name, signature and current address details
Personal Information
I am seeking my own personal information and include proof of my identity.
My date of birth is: ..................................... [DE Staff ID number (if relevant): ..................................... ]
If you are applying on behalf of another person (not your own child), please provide written authority and ID from that person as
privacy issues may apply. You also need to provide your ID.
I am seeking personal information about my child: (name) ……………………………………………………
Date of birth of child is: .............................. I include proof of identity for me and my child (see note below).
Name of last school attended: …………………………………………… Last school year: ....................
Please provide identification for both you and your child and proof of your relationship (e.g. child’s birth certificate
or passport, your Benefit Card or Medicare Card showing child’s name). If your child is over 12 years old, your child
needs to give you written authority, as privacy issues may apply.
Processing charges
You may be asked to pay a charge for processing the application ($30 per hour). If a charge applies, we
will provide you with an estimate of the total payable.
In some circumstances the processing charge may be reduced. If processing charges apply you may
wish to request a reduction, if so please provide evidence of why you are doing so. A 50% reduction
automatically applies to holders of a current Pensioner Concession Card issued by the Commonwealth,
full-time students and non-profit organisations.
Signature and declaration
I declare that the information I have provided on this form is true and correct.
Signed ………………………………………………………… Date .....................................
Privacy Notice
The information provided on this application form is being obtained for the purpose of processing your GIPA application. Providing this
information is required by law. It will be stored securely. If you do not provide all or any of this information it could prevent or delay the
processing of your GIPA application.
Please post this form to: ENQUIRIES AND CONTACT:
Manager, Information Access Unit
Information Access Unit
Department of Education
T: 9561 8151 F: 9561 1157
GPO Box 33
Email:
xxxxxx@xxx.xxx.xxx.xx
Sydney NSW 2001
Website:
www.dec.nsw.gov.au/information-access
Or lodge it at: Information Access Unit
Department of Education
35 Bridge Street
Sydney NSW 2000
DEPARTMENT OF EDUCATION - Credit Card Payment Form
Enter the details of the payment below. All fields marked with an asterisk
must be completed
Family Name:
Family name of person
making the application
Given Name:
Given name of person
making the application
Cardholder name:
Name on Credit Card
Card Number:
_ _ _ _ /_ _ _ _ /_ _ _ _ /_ _ _ _
Card Type:
or
only
Card Expiry Date:
/
e.g. 05/18
Amount:
$
An application fee under
the GIPA Act is $30
Optional:
Paying:
Application Fee payment
Send receipt to:
Advanced Deposit Processing Charges
Mailing address or Email
Balance Processing Charges
Processing Charges – Total Amount
(Please forward with your access application form.)
Merchant Details
Merchant Name:
Department of Education
ABN:
403 0017 3822
Address:
GPO Box 33
SYDNEY
NSW
2000
Email Address:
xxxxxx@xxx.xxx.xxx.xx
Phone:
(02) 9561 8100
Website:
http://www.dec.nsw.gov.au
This form will be securely stored until payment has been confirmed. Once payment is confirmed, the credit card
information will be destroyed according to Departmental procedures.
Document Outline