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 fil ing out this form, please
contact the Right to Information Officer on (02) 9865 2457 or visit our website at www.waternsw.com.au.
1.
Your details
Surname:
...........................................................................................
Title: Mr / Ms
Other names:
.....................................................................................................................
Postal address:
...................................................................................
Postcode: .............
Day-time telephone: ............................................
Facsimile: .....................................................
Email:
.....................................................................................................................
The questions below are optional and the information will only be used for the purposes of providing better service.
Place of birth:
…………………………………..
Main language spoken: ……………………..
Aboriginal or Torres Strait Islander:
Yes / No (circle one)
Do you have special needs for assistance with this application: ................................................
………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………..
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 agency may refuse to process your
application.
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Are you seeking personal information?
Yes / No (circle one)
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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 cheque / money order (circle one) to Water NSW.
(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 – please attach supporting documentation (eg a pension or Centrelink
card).
AND / OR
Special benefit to the public – please specify why below:
..........................................................................................................................................................
..........................................................................................................................................................
Applicant’s signature: .........................................................................
Date: .................................................................................................
Privacy Note: 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 post this form or lodge it at:
Water NSW, PO Box 398 PARRAMATTA NSW 2124
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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