Access (HRIPA & PPIPA) Request Form

Health Records & Information Privacy Act 2002 and Privacy & Personal Information Protection Act 1998

ABOUT THIS FORM

This form is to be used for access and/or disclosure of documents held by the council within files or stored electronically on council’s records management system.

COPIES OF PLANS

If you seeking copies of plans, in particular, house plans, please submit a Plan Request.

YOUR PRIVACY

Port Stephens Council is committed to protecting your privacy. We take reasonable steps to comply with relevant legislation and Council policy.

Purpose: Public access to Council’s documents.

Intended recipients: Council staff and is publicly available under the Government Information Public Access Act 2009.

Supply: Voluntary

Consequence of Non Provision: Insufficient information will be provided.

Storage and security: This document will be placed on the relevant file and/or saved in Council’s records management system in accordance with Council policy and relevant legislation.

Access: Please contact Council on (02) 4980 0255 to enquire how you can access information.

Form cannot be submitted until all field errors on this page have been fixed.

APPLICANT DETAILS

Are you applying as an individual or Company?: *

Individual
Company

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Title: *

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First Name: *

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Middle Name(s): *

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Surname: *

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Home Phone: *

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Mobile Number: *

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Contact name: *

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Company / Organisation Name: *

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ABN: *

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Office Number: *

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Fax: *

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Email Address: *

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APPLICANT'S PHYSICAL ADDRESS

Physical Address: *

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Physical Address Line 2: *

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Physical Address Line 3: *

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Suburb: *

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State: *

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Postcode: *

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Is the postal address different to the physical address?: *

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APPLICANT'S POSTAL ADDRESS

Postal Address: *

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Postal Address (Line 2): *

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Postal Address (Line 3): *

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Suburb: *

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State: *

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Postcode: *

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Please indicate if you agree to receive correspondence at the above email address: * Please note that even if consent is provided, correspondence will be sent to the nominated email at Council’s discretion.

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Date: *

Invalid date.

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Invalid date.

Date:

today

Name:

User type:

Form cannot be submitted until all field errors on this page have been fixed.

GOVERNANCE 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.

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Supporting Documentation: * Please upload any documentation to support your application, if applicable (maximum 10 MB per file; limit 3 files).

Use the "Choose files" button (above) or drop files here to upload.

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File Name:

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Draw On Image:

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PROOF OF IDENTITY

Are you requesting access to your personal information?: *

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When seeking access to personal information, an applicant must provide proof of identity in the form of a certified copy of any one of the following documents: * Only required when an applicant is requesting information on their own behalf.

Australian driver’s license with photograph, signature and current address
Current Australian passport
Other proof of signature and current address details

Required field

Proof of identity: * (maximum 10 MB per file; limit 3 files)

Use the "Choose files" button (above) or drop files here to upload.

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File Name:

File Description:

Draw On Image:

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Applicant signature: *

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Date of Signature: *

Invalid date.

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Invalid date.

Form cannot be submitted until all field errors on this page have been fixed.

You must indicate that you are not a robot.

Your form cannot be submitted until all mandatory questions are answered and any errors corrected. Tabs with errors or missing answers have been highlighted. Please continue or 'save draft'.

Form cannot be submitted while file uploads are in progress.

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Save Draft: Authentication Required

This form requires an authentication code to be sent as an SMS message when retrieving a saved draft submission.

Please enter the phone number which will receive the SMS for retrieving the saved draft submission:

Please enter a valid mobile phone number without spaces e.g. 0400123456.