Credit Card Payments for Access Applications
Government  Information (Public Access) Act  2009
Applicant Details
Surname:
Given name(s):
Business name:
Daytime contact phone number:
If this is an application for an internal review please add the Access Application Number:
Payment Type
Please indicate the reason for making this payment. (Tick the appropriate box)
Formal application:
$30
Internal review:
$40
Advance deposit - 50% initial payment:
$
Advance deposit - Final payment:
$
Credit Card Authority
Please debit my credit card the amount of $
Card type:
MASTERCARD
VISA
Card number
Cardholder's name
/
Expiry date
Cardholder Signature
TfNSW  is  collecting  this  information  so  that  we  can  process  the  fees  for  your  GIPA  application  or  internal  review 
request. We will process the request using a secure interface with Westpac Banking Corporation, and will not disclose 
the information to any other third party. The information will be held securely at 18 Lee Street Chippendale 2008.
Credit Card Payments for GIPA Access Applications  - Form No. 5323 (November 2015)  

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