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Internal Review Application Form

Government Information (Public Access) Act 2009

About this form

ABOUT THIS FORM

This form should be used if you wish to apply for internal review of a decision made under the Government Information (Public Access) Act 2009 (GIPA Act).

You must lodge this form within 20 working days after notice of the decision was given to you.

If you need help in filling out this form, please contact Council's Right to Information Officer by telephone 02 4980 0255.

General information about accessing government information under the GIPA Act is available on the IPC’s website: www.ipc.nsw.gov.au and on Council's website www.portstephens.nsw.gov.au

FEES AND CHARGES

A prescribed fee of $40.00 is payable upon submission of this form.

Please reference Councils prescribed schedule of Fees and Charges for further information.

YOUR PRIVACY

Copy charges may apply in accordance with Council’s adopted fees and charges. Please ask staff for further details. 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 the form may be publicly available under the Government Information (Public Access) Act 2009.

Supply: Voluntary.

Consequence of Non Provision: Failure to complete the form may result in insufficient information being 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) 4988 0255 to inquire how you can access information.

APPLICANT DETAILS

Are you applying as an individual or Company?: *

Individual
Company

Title: *

First Name: *

Middle Name(s): *

Surname: *

Home Phone: *

Mobile Number: *

Contact name: *

Company / Organisation Name: *

ABN: *

Office Number: *

Fax: *

Email Address: *

APPLICANT'S PHYSICAL ADDRESS

Physical Address: *

Physical Address Line 2: *

Physical Address Line 3: *

Suburb: *

State: *

Postcode: *

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

APPLICANT'S POSTAL ADDRESS

Postal Address: *

Postal Address (Line 2): *

Postal Address (Line 3): *

Suburb: *

State: *

Postcode: *

Do 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.

Date: *

Date:

Name:

User type:

Signature of Applicant: *

Date of Signature: *

DECISION DETAILS

Would you like the entire decision reviewed?: *

Yes, what is the decision to be reviewed (s80 of the GIPA Act)?: *

No, what particular aspect of the decision would you like reviewed (s82(3)) of the GIPA Act)?: * Please include in your internal review application the Notice of Decision.

Date of Decision: *

File Reference: *

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