Credit Card
Payment Authority
Freedom of Information Request
To make a credit card payment of the charges associated with processing your Freedom of Information request
with the Department of Infrastructure, Transport, Regional Development and Communications (the department),
please complete your credit card details below.
Please charge:
Bankcard
MasterCard
Visa
Cardholder’s Name:
Credit card number:
Expiry date:
Credit card CVV number:
the amount of $_________:_________ for payment to the department
Cardholder’s Signature:
Contact Details
(phone and email)
To make your payment, please forward this signed form either:
by mail to:
by fax to:
Attn: FOI Coordinator
(02) 6275 1347
Department of Infrastructure, Transport, Regional
Development and Communications
by email to:
GPO Box 594
xxx@xxxxxxxxxxxxxx.xxx.xx
Canberra ACT 2601
Please provide the tracking number of your Freedom of Information request:
FOI 21-_______
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The Department is col ecting this information for the purposes of processing a payment regarding your FOI application under the Freedom
of Information Act 1982. Information wil not be disclosed to any third parties. If you do not provide the information requested payment
may be delayed or not processed. The Department’s on-line privacy policy contains information regarding complaint handling processes
and how to access and/or seek correction of personal information held by the Department. The Privacy Officer can be contacted on
(02) 6274 6495 or at xxxxxxx@xxxxxxxxxxxxxx.xxx.xx.
GPO Box 594 Canberra ACT 2601 Australia Telephone: 02 6274 6495 Facsimile: 02 6275 1347
Website: www.infrastructure.gov.au ABN 86 267 354 017