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Enquiries and contact
xxxx@xxx.xxx.xxx.xx or
Right to Access
Manager, Right to Access
T: 02 7814 3525
Department of Education
Email: xxxx@xxx.xxx.xxx.xx
GPO Box 33
Website: https://education.nsw.gov.au/about-
Sydney NSW 2001
us/rights-and-accountability/information-access
Government Information (Public Access) Act 2009 – GIPA Act
ACCESS APPLICATION
Before you fill in this form please read the department’s agency information guide at https://education.nsw.gov.au/about-
us/rights-and-accountability/information-access and look to see whether the information you want is already available on
our website. If in doubt, contact Right to Access and ask them if the information is already available or can be made available
without a formal access application under the GIPA Act.
Applicant details
Family name:
Title: Mr / Ms / other
Other names:
Postal address:
(compulsory)
Postcode:
Day-time telephone:
Mobile:
Email:
I agree to exclude from the scope of my application the personal information of any third parties for whom I
have not provided authority.
I agree to the release of my/my client’s/my child’s name to any third parties the department may need to
consult as part of my application. I understand that not agreeing could affect the outcome of my application.
Have you made an application for the same or similar information from another agency? Yes
No
Name of other Agency:
I would like the following information from the department:
Note: For your application to be processed, you need to provide enough details for us to identify the information you want. For help go
to the above website or contact Right to Access.
Please give the date range the information is to cover: .................... to ...................
Optional: My reason for making this application:
Application Fee $30
Attach Credit Card payment (last page of this document contains credit card payment form) (preferred) or
pay the
$30 application fee by cheque or money order made out to:
NSW Department of Education
Personal Information
I am seeking the personal information of:
Myself
My child
My client
My/child’s/client’s date of birth is:
DE Staff ID number (if relevant):
Proof of identify, proof of relationship and written authority has been provided where relevant.
If seeking school records
*Name of last NSW government school attended:
Last school year:
* If the last attended NSW government school name is not provided your application will be considered invalid.
Proof of Identity and authority required for personal information
Proof of identity is required when requesting personal information in order to comply with privacy requirements.
Please provide a copy of the following documents with your application for yourself, your client or your child.
Applying for own
Applying for own child’s records
Applying for client/third party’s records
records
Signature ID
Parent/carer signature ID
ADULT
Current Australian
ID with proof of relationship
Client/third party’s ID
photo driver’s licence,
(Medicare card or birth certificate
Client/third party’s authority
Australian passport, or
showing both parent/carer and child CHILD
other proof of name,
names)
Parent/carer signature ID
signature and current
Child’s authority form for counselling
Proof of relationship (Medicare card or birth
address details
records (if over 12 years old)
certificate showing both parent/carer and child
names)
Client/third party’s authority
Child’s authority form for counselling records
(if over 12 years old)
Form of access
We will provide you with a copy of the released information electronically where possible. Please advise if you
require access in another way.
Processing charges
You may be asked to pay a charge for processing the application ($30 per hour). If a charge applies, we will
provide you with an estimate of the total payable before charges are incurred.
In some circumstances the processing charge may be reduced. If processing charges apply you may wish to
request a reduction, if so please provide evidence of why you are doing so. A 50% reduction automatically applies
to holders of a current Pensioner Concession Card issued by the Commonwealth, full-time students and non-profit
organisations.
Signature and declaration
I declare that the information I have provided on this form is true and correct.
Signed
Date
Privacy Notice
The information provided on this application form is being obtained for the purpose of processing your GIPA application. Providing this
information is required by law. It will be stored securely. If you do not provide al or any of this information it could prevent or delay the
processing of your GIPA application.
DEPARTMENT OF EDUCATION - Credit Card Payment Form
Enter the details of the payment below. All information with an asterisk
is mandatory.
Family Name:
Family name of person
making the application
Given Name:
Given name of person
making the application
Cardholder name:
Name on Credit Card
Card Number:
_ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _
Please print clearly
Card Type:
Visa
Mastercard
or
only
Card Expiry Date:
/
e.g. 05/30
Amount:
$
An application fee under
the GIPA Act is $30
Paying: Application Fee payment
GIPA Number:
Advanced Deposit Processing Charges
GIPA- _____ - ______
Balance Processing Charges
Processing Charges – Total Amount
Receipt will be sent to the address provided on your GIPA application.
Merchant Details
Merchant Name:
Department of Education
:
N
B
A
40
3 001
7 382
2
A
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GPO Box 33
SYDNEY NSW 2000
Email Address:
xxxx@xxx.xxx.xxx.xx
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(02) 781
4 35 5
2
Website:
https://education.nsw.gov.au
This form will be securely stored until payment has been confirmed. Once payment is confirmed, the credit card information
will be destroyed according to department procedures.
Document Outline
