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Government Information (Public Access) Act 2009 ACCESS APPLICATION 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 [number] or visit our website at [www.].

1. Your Details Surname:

Irons

*

Other names:

Andy

*

Postal address:

Kauai, Hawaii

*

Day-time phone:

345345

Email:

alan.rivera@oic.nsw.gov.au

*

Facsimile:

Postcode:

3453

*

*

345345

*

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:

Kauai, Hawaii

Aboriginal or Torres Strait Islander

i j k l m n

No

j k l m n

Yes

Do you have special needs for assistance with this application? (Please provide details below)

b c d e f g

I agree to receive correspondence at the above email address

2. Proof of Identity Only required when an applicatn is requesting information on their own behalf. When seeking access to personal information, an application must provide proof of identify in the form of a certified copy of any one of the following documents:

c d e f g

Australian driver's licence (with photograph, signature and current address)

c d e f g

Other proof of signature and current address details

c d e f g

Current Australian passport

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