Freedom of Information (FOI) Application Form
(Section 12 of the
Freedom of Information Act 1992)
Personal Details
1. Preferred Title (Hon/Dr/Mr/Miss/Ms etc): ____________________________
2. Surname: ____________________________________________________
3. Given Name(s): ________________________________________________
4. Australian Postal Address: _______________________________________
_____________________________________________________________
5. Contact Numbers: (Home) ___________________
(Work) ___________________
(Mobile) ___________________
(Fax) ___________________
Reason for FOI Application (please circle)
1. I am seeking access to personal information about myself Yes No
2. I am seeking access to non-personal (third party) information Yes
No
3. I am applying on behalf of a business/organisation
Yes
No
If yes, please write the business/organisation name:
_________________________________________
FOI Access Request
I am applying for access to:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___________________________
Date Range for Document Search (if relevant): From: ___/___/_____ To: ___/___/_____
*Please attach additional information if necessary*
Fees and Charges If you are applying for access to non-personal information (information other than that about
yourself), an application fee of $30 applies (payable by cash or cheque). This fee must be made when
an FOI application is submitted.
In certain cases, a reduction in charges may apply. If you consider that you are entitled to a
reduction, please attach a request and copy of your pension/concession card(s) or other supporting
documentation, together with your FOI application.
NOTE: Please make all cheques out to the “Department of Local Government, Sport and Cultural
Industries – Culture and the Arts”.
Freedom of Information Application Form
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Applicant Declaration I have attached the $30 fee together with my FOI access application and understand that I may be
required to pay further processing charges in respect of this application. Should processing charges
occur, I understand that I will be provided with a statement of charges. Signature: _____________________________
Date: ___/___/_____
Or
Under Regulation 3 of the Freedom of Information Regulations 1993, I am requesting a 25%
reduction in charges on the basis that I am financially disadvantaged and/or the holder of a
pension/concession card. I have attached proof of this documentation together with my FOI access
application. Signature: ____________________________
Date: ___/___/_____
Lodgement of FOI Access Applications
Applications may be made:
By post addressed to:
In Person:
FOI Coordinator
Department of Local Government,
Department of Local Government, Sport and Cultural Industries
Sport and Cultural Industries 2nd Floor Reception
14th Floor, Gordon Stephenson House 140 William Street
140 William Street
Gordon Stephenson House
PERTH WA 6000 PERTH WA 6000
Via Email: “Attn FOI Coordinator”
xxxxxxxxxxxxxxxxxxxxx@xxx.xx.xxx.xx NOTE: An acknowledgement letter will be sent upon receipt of the FOI application.
Further Information If you require further information, please do not hesitate to contact the DLGSC’s FOI Coordinator on
(08) 6552 7361, or visi
t www.dca.wa.gov.au.
Freedom of Information Application Form
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