NT Police, Fire and Emergency Services
Contact Us
Information Access Team
PO Box 39764
Freedom of Information (FOI)
WINNELLIE NT 0821
Application Form
Telephone: (08) 8985 8926
xxxxxx.xxxxxxxxxxx@xx.xxx.xx
Use this form to apply for any information held by NT Police, Fire and Emergency Services
except CCTV
footage taken from the City Safe Cameras, Motor Vehicle Crash Reports, General Property Insurance
Reports, Complete Traffic History Checks, National Police Certificates or OCHRE cards. For further
information in relation to your request, please do not hesitate to contact us.
Please send your completed application form including a clear certified copy of your photo ID and proof of
payment (if applicable) to the Information Access Team by email or mail. If you submit your form at an NT
Police Station, the receiving officer will certify your photo ID and forward your application to the Information
Access Team for you.
Your Name and Contact Details
Title (please circle): Ms / Mrs / Miss / Mr / Dr_________
Postal Address:
First Name:___________________________________
_________________________________________
Family Name:_________________________________
_________________________________________
Phone: (B/H)_____________(A/H)________________
_________________________________________
Email:_______________________________________ Fax:______________________________________
Describe the Information you Want
Please provide as much detail about the information you want, e.g. dates created, location, subject matter,
who was involved. (Attach another sheet of paper with more details, if necessary)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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Preferred Form of Access (please tick relevant box)
Hard copy sent by mail
Electronic copy sent by email
Inspection
Other (please specify) __________________________________________________________
Application Fee - $30 (please tick relevant box)
If your application is only for records that contain personal information about you, there is no application fee.
However, if your application is for information that is not about you, or for a mix of non-personal and personal
information, you must pay an application fee. In some cases, the fee may be waived or reduced.
I limit my application to records that contain personal information about me (no application fee)
I attach a $30 cheque / money order / receipt for the application fee
I attach a completed Application to Waive/Reduce Fees form in relation to the application fee
Processing Fee (please tick relevant box if applicable)
A processing fee may be charged to cover costs of processing the application. If your application is only for
records that contain personal information about you, the processing fee is more limited. In some cases, the fee
may be waived or reduced.
I understand that I may have to pay a processing fee in relation to the application
I attach a completed Application to Waive/Reduce Fees form in relation to the processing fee
Identification
Section 18(3) of the
Information Act (NT) stipulates that a public sector organisation must satisfy itself as to the
identity of the applicant prior to accepting an application. Satisfactory forms of identification are driver’s
licence/18+card/passport.
Sign Here ___________________________________
Date _____________________________________
Privacy
Northern Territory Police, Fire and Emergency Services (NTPFES) is collecting this information to ensure that
the correct person is entitled to receive the information requested. This collection is authorised or required by
the
Information Act (NT) and/or the Northern Territory
Police Administration Act. The information provided on
this form is only used to identify the applicant for the purpose of providing the information requested. You have
the right to request access to any of your personal information held by NTPFES. For more information, please
contact NTPFES by telephone on (08) 8985 8926.
This must be completed by the Receiving Officer before forwarding to the Information Access Team
Date Application Received:__________________________________________________________________
Photographic Identification of Applicant Attached: Yes
Receipt Number:_________________________________ Payment Amount:__________________________
Receiving Officer’s Name & Position (please print):_______________________________________________
Signature of Receiving Officer:_______________________________________________________________
Updated: July 2015
NT Police, Fire and Emergency Services
Contact Us
Information Access Team
PO Box 39764
Freedom of Information (FOI)
WINNELLIE NT 0821
Payment Options
Telephone: (08) 8985 8926
xxxxxx.xxxxxxxxxxx@xx.xxx.xx
Bank Transfer via Internet or Telephone Banking – only within Australia
Our bank details are:
National Australia Bank (NAB)
Account Name: Receiver of Territory Monies (RTM)
BSB: 085-461
Account Number: 161610000
Description: Applicant’s/Your Name – 166311
You must also attach a copy of the transfer confirmation to this application form and send it to the Information
Access Team at NT Police, Fire and Emergency Services.
Credit Card – this is the only method of payment for overseas customers
Credit card payments can be made to the Receiver of Territory Monies (RTM) over the telephone or by email.
You must advise the RTM that you are paying for a Freedom of Information Request under the
Information
Act, with the general ledger code
16 BEG 745 - 166311 and tax code
N00. You must also attach a copy of the
RTM receipt to this application form and send it to the Information Access Team at NT Police, Fire and
Emergency Services.
The RTM can be contacted during office hours on
(08) 8999 1606 or by email xxxxxxxxx@xx.xxx.xx
Cheque / Money Order
Cheques and money orders should be made payable to the Receiver of Territory Monies (RTM) and sent with
the completed application form to the Information Access Section of NT Police, Fire and Emergency Services.
Updated: July 2015
