Application for access to Council information
Government Information (Public Access) Act 2009 (NSW)
How to lodge this application
Post: Blue Mountains City Council, Locked Bag 1005, Katoomba, NSW 2780
In person: 2-6 Civic Pl, Katoomba NSW 2780  or  104 Macquarie Rd, Springwood NSW 2777
Fax: (02) 4780 5555  Email: xxxxxxx@xxxx.xxx.xxx.xx
Important information about this form: Please read carefully before completing your application
1.  This form is to be used for access to information held by Council. 
2.   Council will provide access to information it holds except where there is a legal requirement exempting Council  
from releasing the document or where there is an overriding public interest against disclosure of the information.
3.   Requests for information that contains personal or business information are subject to consultation with  
those parties. 
4.  Applications for access to information will be assessed according to relevant legislation and Council procedures. 
Fees and charges:
1.  There is no application fee for informal requests. Fees may apply for Council publications or for photocopying. 
2.   There is a $30 application fee for formal applications under the Government Information (Public Access) Act 2009 NSW 
(‘GIPA Act’).
3.   A processing charge of $30 per hour for formal applications under the GIPA Act will also apply if the information  
requested does not relate to the applicant’s personal affairs or if a request for personal information takes more than  
20 hours to process. A 50% reduction in fees may be granted for applicants claiming financial hardship or special  
public benefit reasons when requesting the information. Estimates will be provided prior to commencing the  
information search.
Application details
 
 I am submitting an informal request for access to Council information (no application fee)
 
 I am submitting a formal request for access to Council information ($30 application fee)
Note: Council encourages applications to be made as informal applications in the first instance. However, Council may advise 
that certain applications, such as those involving third party information may need to be made as formal applications.
Applicant’s details
Surname:  
Given Names: 
                          
         Title:  
Company (if applicable):  
Postal Address:  
 
 
 
 
 
 
 
 
Postcode:  
Telephone number:  
 
Mobile:
Email address: 
Preferred method of contact: 
I am making this application on behalf of another person:  
Yes* 
No
* If yes, please ensure that you complete this form as yourself and attach relevant consent documentation.

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Information requested 
1.  Please describe the information (e.g. documents) that you are requesting:
2.  This information relates to my personal affairs:           Yes (identification required)   
No
3.  Would you like to provide additional details that may assist us with your application?
4.  Form of information requested:            Inspection only 
                 Electronic copy                            Hardcopy
Attachments to this form
Certified copy of my identification  
 
 
 
 
        Yes   
         No
Evidence of authority to request information on behalf of another person  
        Yes   
         No
Signature
As the applicant, I declare that:
1.  The information given on this form is true and correct.
2.  I agree to pay any and all required fees associated with this application.
3.  I understand that I must seek the copyright owner’s consent in order to use any part of a copyright document. 
Signed: 
 
        Date: 
 
Privacy Protection Notice: The personal information 
If you do not provide Council with this information, we 
that Council is collecting from you is personal information 
may be unable to process or complete your application. 
for the purposes of the Privacy and Personal Information 
Access and Correction: You may make an application  
Protection Act 1998 (PPIPA).
to access or amend information held by Council.
Intended recipients: The intended recipients of the  
Storage: Council is the agency that holds and controls  
personal information are officers within the Council. 
the information: Locked Bag 1005, Katoomba NSW 2780
Reason for collection: Council is collecting this personal 
Enquires about this form: Contact the Privacy Contact 
information from you in order to process your information 
Officer, Locked Bag 1005, Katoomba NSW 2780  
request.
(xxxxxxx@xxxx.xxx.xxx.xx; (02) 4780 5000.
Supply: The supply of information by you is voluntary.  
Office use only:
Ledger no:                                              Receipt no:                                         Amount Received:                                       Date:  
1. Original to Records ASAP 
 
2. Copy to Information Access Officer

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