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NSW POLICE FORCE
Credit Card Payment Form
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Government Information (Public Access) Act 2009
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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.
APPLICANT DETAILS
First & Other Name/s
Last Name
Business Name (If applicable)
ABN
Contact Phone Number
Email Address
PAYMENT
Please select the reason for making this payment and select/input the payment amount
Access Application
Amount $30.00
Internal Review
Amount $40.00
Advance Deposit – Initial 50% Payment
Amount
Advance Deposit – Final Payment
Amount
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
Card Type
VISA
MASTERCARD
Expiry Date - Month -
- Year -
Card Number
Card Holder Name
Card Holder Signature
Date
Note: 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
Application Date
Receipt Number
Successful Payment
Unsuccessful Payment
Date
Version: July 2018
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