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 9351 4263 or visit our website at www.sydney.edu.au/arms
1. Your
details
Surname:
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Title: Mr/Ms/Dr/Prof
Other names:
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Postal address:
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Postcode: .............
Day-time telephone:
.............................................
Facscimile: ....................................................
Email:
.......................................................................................................................
Staff or student number (University staff or students only) .............................................................
I agree to receive correspondence at the above email address.
2. Government
information
Please describe the information you would like to access in enough detail to allow us to identify it.
Note: If you do not give enough details about the information, the University may refuse to process your
application.
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Are you seeking personal information?
Yes / No (circle one)
Privacy
The information you supply on this form is required by the University to deal with your application. The information will
not be disclosed except in accordance with the University’s Privacy Policy. Questions regarding access or correction
should be addressed to the Right to Information Officers. Further details at sydney.edu.au/arms/privacy
Application Form_A1_v3_1.doc (Jan 2010)
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Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
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) made out
to the University of Sydney. (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 the agency’s ‘disclosure log’. This is published
on the agency’s website.
Do you object to this?
Yes /
No (circle one)
6.
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 – (eg, full time student, a pension or Centrelink card holder or non-profit
organisation).
AND
/
OR
Special benefit to the public – please specify why below:
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Applicant’s signature: ...........................................................................
Date: ....................................................................................................
Please post this form to:
Right to Information
Archives and Records Management Services
c/- Archives A14
University of Sydney 2006
General information about the GIPA Act is available by calling the Office of the Information Commissioner on
freecall 1800 194 210 or at its website: <www.informationcommissioner.nsw.gov.au>.
Office use only
Date application received: ................................................................................
File reference: ...................................................................................................
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