Please note the University will be closed between 21 December 2016 and 4 January 2017.
To reflect this closedown period we may request an extension of time to process your
application.
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 +61 2 4985 4529 or visit
our website.
1.
Your details
Surname:
............................................................................................
Title: Mr / Ms
Other names:
.....................................................................................................................
Postal address:
................................................. ...................................
Postcode: .............
Day-time telephone: ............................................
Facsimile: .....................................................
Email:
.....................................................................................................................
Do you have special needs for assistance with this application:…………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
I agree to receive correspondence at the above email address.
2.
Details of Request
Please describe the information you would like to access in enough detail to allow us to identify
it.
You may also provide a submission on any considerations in favour of disclosure of the information you
seek. This will be taken into account in balancing the public interest test. It is your responsibility to inform
the GIPA Officer of any such considerations.
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 your own personal information?
Yes / No (circle one)
3.
Proof of identity
Only required when an applicant is requesting information on their own behalf.
If you are seeking access to personal information about yourself, you must provide proof
of your identity in the form of a certified copy of any one of the following documents:
Australian driver’s licence
with photograph, signature and current address
Passport
Current University of Newcastle student card
Other proof of signature and current address details
4.
Third Party Consultation
If you are seeking information that concerns the interests of another party the University may be
required to consult with them before deciding your application. The third party then has a right to
object to that release.
The University will not identify an individual to the third party without your consent, however, in
some instances the third party may be able to deduce the identity of the applicant.
In some instances it may help the third party, in deciding whether or not to object to the release,
to know the identity of the applicant.
If you consent to your name being provided to a third party where requested please check this
box
5.
Form of access
How do you wish to access the information?
Inspect the document(s)
Receive a copy of the document(s)
Access in another way (please specify) ......................................................................................
6.
Application Fee
I attach payment of the
$30 application fee by card / cheque / money order (circle one).
7.
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)
8.
Discount in processing charges
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:
..........................................................................................................................................................
..........................................................................................................................................................
Note: If you have included a submission above that indicates there is a special benefit to the public please
write
see above.
Applicant’s signature: .........................................................................
Date: .................................................................................................
PAYMENT:
Name: ____________________________ Student Number (if applicable) ______________
[ ] I enclose a cheque/money order for $. . . . . . . . . .
[ ] Please debit my Credit Card for $ . . . . . . . .
MASTERCARD [ ] VISA [ ]
CREDIT
EXPIRY
/
CARD NO:
DATE:
CARDHOLDER’S NAME: . . . . . . . . . . . . . . . . . . . . . . . . . .
CARDHOLDER’S SIGNATURE: . . . . . . . . . . . . . . . . . . . . .
OFFICE USE ONLY:
COST CENTRE & ACCOUNT CODE: 10100224781
GST: NOT APPLICABLE
Applicable Photo ID Sighted: YES [ ]
NO [ ]
Your Privacy
The University of Newcastle is subject to the Privacy and Personal Information Protection Act 1998 and the Health
Records and Information Privacy Act 2002. The personal information you provide in relation to your application will be
protected in accordance with the University Privacy Management Plan and will be used by the University in order to
process your application. If you do not complete all the questions on this form, it may not be possible to process your
application. Your personal information will be stored securely. You may access and correct your personal information by
contacting this office. The University of Newcastle will not disclose your personal information without your consent
unless the University is under a legal obligation to do so. By signing this application it is understood that you have read
this statement and agree to the use and disclosure of your personal information as detailed in this form. Full details of the
University Privacy Management Plan can be foun
d here.
