Formal Access Application
Government Information (Public Access) Act 2009
Please complete this form to apply for formal access to government information under the
Government
Information (Public Access) Act 2009 (NSW). If you need help to complete this form, please contact City of
Newcastle’s Legal and Information Officer on (02) 4974 2435, or visit our website at www.newcastle.nsw.gov.au
and search for Council/Access to information.
1. Your details
Business / Group Name........................................................................................................................................
(if the application is lodged on behalf of a business or a group)
Surname................................................................................................................
Title..........................................
First Name..............................................................................................................................................................
Postal address.......................................................................………..….........
Postcode.......................................
Telephone.......................................................................
I would like to receive correspondence at my email address
Email..................................................................
2. Proof of identity
Only required when you are requesting information on your own behalf.
Are you seeking access to
your personal information?
Yes
No
When seeking access to personal information, you must provide proof of identity in the form of a certified
copy of any one of the following documents:
Driver’s licence
Other proof of signature and current address details
3. Government information
Please describe the information you would like to access
(attach another page if more space is required).
Note: If you do not give enough detail about the information sought, we may refuse to process your application
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Are you seeking personal information?
Yes
No
If you have applied at any time to another agency for substantially the same information, please provide the
name of the other agency .................................................................................. ................................………….…
4. Third Party Consultation
If the information you are requesting contains information about another person or business, we may be required
to consult with third parties before deciding your application. The purpose of this consultation is to determine
whether the third party has an objection to disclosure of some or all their information being requested. This
information may assist the third party to understand why you are seeking their information.
Please advise if you consent to us disclosing the following information to a third party as part of our consultation:
Your identify as the GIPA applicant (name):
Yes
No
The government information described in the application (point 3 above):
Yes
No
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5. Form of access
How do you wish to access the information? (tick one option only)
Inspect the document(s)
Receive a copy of the document(s)
Access the document(s) in another way (please specify)……………………..……………………………………...
6. Application Fee
$30 application fee to be paid:
in person (cash / cheque / money order / credit card)
by mail (cheque / money order only)
Note: do NOT send cash by post
by telephone (credit card only - processing surcharge may apply)
Note: we will call you once the application
has been received to arrange payment.
7. Discount in processing charges
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 pension or Centrelink card)
Special benefit to the public - please specify why, or attach supporting documentation.
8. Disclosure log
If the information sought is released to you and would be of interest to other members of the public, specific
details about your application may be recorded on our disclosure log. This is published on our website.
Do you object to this? Yes
No
Applicant’s signature………………………………………………………………………..Date.....................................
Protecting your privacy
City of Newcastle (CN) is committed to protecting your privacy and takes reasonable steps to comply with al
relevant legislation. The information is collected by CN for the purpose of processing your application. Your
personal information will be stored in accordance with relevant legislation and will only be accessed by authorised
CN Staff. If you do not provide information, CN may not be able to process your application. Your information
can be checked for accuracy by contacting CN on (02) 4974 2000.
Lodging your Formal Access Application
In person
By mail
By email
City of Newcastle
City of Newcastle
xxxx@xxx.xxx.xxx.xx
Administration Centre
PO Box 489
12 Stewart Avenue
Newcastle NSW 2300
Newcastle West NSW 2300
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