NSW POLICE FORCE
Credit Card Payment Form
Government Information (Public Access) Act 2009
This form is to be completed when paying by Credit Card for access to information under the provisions of
the Government Information (Public Access) Act 2009 (GIPA Act).
You must submit this form with your application.
First & Other Name/s
Contact Phone Number
Please select the reason for making this payment and select/input the payment amount
Advance Deposit – Initial 50% Payment
Advance Deposit – Final Payment
CREDIT CARD AUTHORITY
The NSW Police Force is col ecting this information so that we can process the fees for your GIPA Act Application or Internal
Review request. We wil process the request using a secure interface with Westpac Banking Corporation,
and wil not disclose the information to any other third party.
Please debit my credit card to the amount of
- Month -
- Year -
Card Holder Name
Card Holder Signature
: By signing as the cardholder, you confirm that you are the owner or authorised signatory of the Credit Card and
details of the same provided above and you acknowledge that it is an offence to provide false or misleading information.
FOR INFOLINK ONLY
Application Reference Number
Version: July 2018
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