Credit Card
Payment Authority
Freedom of Information Request
To make a credit card payment of the charges associated with processing your Freedom of Information request
with the Department of Infrastructure and Regional Development, please complete your credit card details
below.
Please charge:
Bankcard
MasterCard
Visa
Cardholder’s Name:
Credit card number:
Expiry date:
CCV/CCV2 Security code*:
the amount of $_________:_________ for payment to The Department of Infrastructure and Regional Development
for the charges associated with processing my Freedom of Information Request.
Cardholder’s Signature:
Contact Phone:
Contact Email:
To make your payment, please forward this signed form either:
by mail to:
by fax to:
Freedom of Information Coordinator
(02) 6275 1347
0B
Department of Infrastructure and Regional Development
by email to:
1B
GPO Box 594
xxx@xxxxxxxxxxxxxx.xxx.xx
2B
CANBERRA ACT 2601
Please provide the tracking number of your Freedom of Information request:
FOI _________
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The Department of Infrastructure and Regional Development (the Department) is collecting this information for
the purposes of processing a payment regarding your FOI application under the Freedom of Information Act 1982.
Information will not be disclosed to any third parties. If you do not provide the information requested payment
may be delayed or not processed. The Department’s on‐line privacy policy contains information regarding
complaint handling processes and how to access and/or seek correction of personal information held by the
Department. The Privacy Officer can be contacted on (02) 6274 6495 or at <xxxxxxxxxxxxx@xxxxxxxxxxxxxx.xxx.xx>
GPO Box 594 Canberra ACT 2601 Australia Telephone: 02 6274 7111 Facsimile: 02 6275 1347
Website: www.infrastructure.gov.au ABN 86 267 354 017
* Visa/MasterCard
The CCV/CCV2 security code for your
MasterCard or Visa card is the three-digit
number on the back of your credit card,
immediately following your main card number.