This is an HTML version of an attachment to the Freedom of Information request 'Recipient of the Professional Development Grant Program'.


   
DoE File Reference GIPA- 
 
Government Information (Public Access) Act 2009 – GIPA Act 
ACCESS APPLICATION 
Before you fill in this form please read the department’s agency information guide at https://education.nsw.gov.au/about-
us/rights-and-accountability/information-access 
and look to see whether the information you want is already available on 
our website. If in doubt, contact our Information Access Unit and ask them if the information is already available or can be 
made available without a formal access application under the GIPA Act. 
 
Applicant details 

 
Family name:   
 .................................................................     Title:  Mr / Ms / Other ……....… 
Other names:   
 ..................................................................................... ....................................... 
Postal address
 ..................................................................................... ........................................  
(compulsory) 
 
 ..................................................................................... Postcode:...................... 
 
Day-time telephone:  ......................................... M: ……………………. ........Fax:……………….......... 
Email (optional):  
 ............................................................................................................. ............... 
   I agree to receive correspondence by email 
   I agree to the release of my name to any other (third) parties the department may need to consult as part of 
my application. I understand that not agreeing could affect the outcome of my application. 
 
I would like the following information from the department: 
 
 
 
 
 

 
 
 
Note: For your application to be processed, you need to provide enough details for us to identify the information you want. For 
help go to the website http://www.dec.nsw.gov.au or contact the department’s Information Access Unit. 
 
Please give the date range the information is to cover: .................... to ...................  
 
Optional: My reason for making this application: 
 
 
 
Application Fee $30  
 
Attach payment of the $30 application fee by cheque or money order made out to:  
Department of Education OR make a credit card payment (last page of this document contains credit 
card payment form) Note: There is no application fee waiver or discount. 
 
Form of access 
 
We will provide you with a copy of the information released. If the information requested is more than 20 
pages we will provide it on a computer disc, otherwise you will receive it by post/email. Please advise if 
you require access in another way.  

 
Proof of Identity required for personal information 
  
For access to your own or your child’s personal information we need you to provide proof of identity. This 
is to comply with privacy requirements. Please provide a copy of the following documents with your 
application: 
•  Australian photo driver’s licence showing current address, or 
•  Current Australian passport, and current address details, or 
•  Other proof of name, signature and current address details 
 
Personal Information 
 
I am seeking the personal information of: 
 
 Myself                   My child ..........................................     My client .............................................. 
 
                                                                  (name)    
 
                     (name)   
and include proof of my/child’s/client’s identity, proof of relationship and written authority (if relevant).  
 
My/child’s/client’s date of birth is: ..................................... [DE Staff ID number (if relevant): ......................... 
 
If seeking school records:  
 
Name of last school attended: ……………………………………………   Last school year: ......................... 
 
PLEASE NOTE: 
If you are applying on behalf of another person (not your own child), please provide written authority and ID from 
that person as privacy issues apply. You also need to provide your ID.  
 
If you are applying on behalf of your own child please provide your ID and proof of your relationship (e.g. child’s 
birth certificate, your Benefit Card or Medicare Card showing both you and your child’s name).  
 
If you are seeking counselling records, and your child/client is over 12 years old, we require your 
child’s/client’s ID and written authority, as privacy issues apply.     
 
 
Processing charges 
 
You may be asked to pay a charge for processing the application ($30 per hour). If a charge applies, we 
will provide you with an estimate of the total payable. 
 
In some circumstances the processing charge may be reduced. If processing charges apply you may 
wish to request a reduction, if so please provide evidence of why you are doing so. A 50% reduction 
automatically applies to holders of a current Pensioner Concession Card issued by the Commonwealth, 
full-time students and non-profit organisations.   
 
Signature and declaration 
 
I declare that the information I have provided on this form is true and correct. 
 
Signed ………………………………………………………… Date ..................................... 
 
Privacy Notice 
The information provided on this application form is being obtained for the purpose of processing your GIPA application. Providing this 
information is required by law. It will be stored securely. If you do not provide all or any of this information it could prevent or delay the 
processing of your GIPA application. 
 
Please email or post this form to:                               ENQUIRIES AND CONTACT: 
Manager, Information Access Unit 
Information Access Unit  
Department of Education  
T: 9561 8100 F: 9561 1157 
GPO Box 33 
Website: https://education.nsw.gov.au/about-us/rights-and-
Sydney NSW 2001           
accountability/information-access  
  Email: [email address] 
 
Or lodge it at: 
Information Access Unit 
Department of Education  
35 Bridge Street Sydney NSW 2000 
 




   
DoE File Reference GIPA- 
 
 
DEPARTMENT OF EDUCATION - Credit Card Payment Form 
 
Enter the details of the payment below. All information with an asterisk  is mandatory. 
 
  Family Name: 
 
Family name of person 
making the application 
  Given Name: 
 
Given name of person 
making the application 
  Cardholder name: 
 
Name on Credit Card 
  Card Number: 
_ _ _ _ /_ _ _ _ /_ _ _ _ /_ _ _ _  
  Card Type:  
 
  
  or  
  only 
  Card Expiry Date: 
                 / 
e.g. 05/17 
  Amount: 

An application fee under 
the GIPA Act is $30 

 
 
 
Paying: 
  Application Fee payment 
GIPA Number: GIPA- ____ - _____ 
                Advanced Deposit Processing Charges 
 
                Balance Processing Charges 
                Processing Charges – Total Amount 
 
Receipt will be sent to address provided   
on GIPA application.  
 
Merchant Details 
Merchant Name: 
Department of Education  
 
ABN: 
403 0017 3822 
 
Address: 
GPO Box 33 
 
 
SYDNEY 
 
 
NSW 
 
 
2000 
 
Email Address: 
[email address] 
 
Phone: 
(02) 9561 8100 
 
Website: 
https://education.nsw.gov.au  
 
 
This form will be securely stored until payment has been confirmed. Once payment is confirmed, the credit card information 
will be destroyed according to department procedures.