Government Information (Public Access) Act 2009
FORMAL ACCESS TO INFORMATION - APPLICATION FORM
Please complete this form to apply for formal access to government information under the
Government Information (Public Access) Act 2009 (GIPA Act). If you need help in filling out this
form, please contact the Right to Information Officer on 9707 0000 or visit our website at
www.cbcity.nsw.gov.au
1. YOUR DETAILS
Surname:
………….…......................................................................................
Title: Mr / Mrs / Ms
Other names: …………………………………………………...……………………………….…………..
Address:
…………………………………………………………………
Postcode: ……………..
Daytime Ph.: …………………...…..…….
Mob: …….………………………….
Fax: …….…………...……...
Email:
………………………………….………………………………………………………..…................
I agree to receive correspondence to the above email address.
The questions below are optional and the information will only be used for the purposes of providing
better service.
Place of birth: ……………………………
Main language spoken: …………………………………..
Aboriginal or Torres Strait Islander: Yes / No (circle one)
Do you have special needs for assistance with this application: …………………………………...
…………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………….
2. PROOF OF IDENTITY
When seeking access to your own personal information, an applicant must provide proof of
identity in the form of a certified copy of any one of the following documents:
Australian driver’s licence
Current Australian passport
with photograph, signature and current address
Other proof of signature and current address details
3. GOVERNMENT INFORMATION
Please describe the information you would like to access in enough detail to allow us to identify it.
Note: If you do not give enough details about the information, the agency may refuse to process your
application.
Are you seeking personal information?
Yes / No (circle one)
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ACCESS TO COPYRIGHT PROTECTED DOCUMENTS
In accordance with Section 72(2)(c) of the
Government Information (Public Access) Act 2009, Council will not
release information that is copyright protected unless the copyright owner has expressly consented in writing.
View access to documents may be provided.
4. FORM OF ACCESS
How do you wish to access the information?
Inspect the document(s)
A copy of the document(s)
Access in another way (please specify) ………………………………………………………………...
………………………………………………………………………………………………………………….....
5. LODGEMENT OF APPLICATION AND APPLICATION FEE
I attach payment of the
$30 application fee by cash / cheque / money order (circle one).
(Note: please do NOT send cash by post and cheques to be made payable to Canterbury-Bankstown Council)
In Person:
Mail to:
Bankstown Office
Canterbury-Bankstown Council
Customer Service Centre
PO Box 8, BANKSTOWN NSW 1885
Upper Ground Floor of Civic Tower
66-72 Rickard Road, BANKSTOWN NSW 2200
Campsie Office
Administration Centre
137 Beamish Street, CAMPSIE NSW 2194
Governance
Issue No. 2
Issue Date: July 2017
Page 2 of 3
6. DISCLOSURE LOG
If the information sought is released to you and would be of interest to other members of the public,
details about your application may be recorded in the agency’s ‘disclosure log’. This is published
on the agency’s website.
Do you object to this?
Yes /
No (circle one)
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 (e.g. a pension or Centrelink
card).
AND / OR
Special benefit to the public – please specify why below:
..........................................................................................................................................................
Applicants’ signature: ................................................................
Date: ........................................................................................
PRIVACY STATEMENT
Council is required under the Privacy and Personal Information Protection Act 1998 (PPIPA) to collect,
maintain and use your personal information in accordance with the Privacy Principles and other relevant
requirements of the PPIPA.
Personal information requested on this form will only be used to fulfil the purpose for which it is being collected.
Provision of this information is voluntary and is required to help process your application. Council is regarded
as the agency that holds the information and access is restricted to council officers and other authorised
people. You may apply to access or amend the information. For further information or clarification please
contact the Privacy Contact Officer at Council.
Governance
Issue No. 2
Issue Date: July 2017
Page 3 of 3
Document Outline
