Government Information (Public Access) Act 2009

INTERNAL REVIEW APPLICATION FORM

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 the Council on 9707 9000. General information about accessing government information under the GIPA Act is available on the IPC’s website: www.ipc.nsw.gov.au

1. Applicant Details

Title *

First Name *

Last Name *

Address *

Postal address if different

Phone

Mobile *

Email Address *

2. Decision Details

GIPA Reference Number *

Date of decision *

Would you like the entire decision reviewed? *

YesNo

What is the decision to be reviewed (s80 of the GIPA Act)? *

What particular aspect of the decision would you like reviewed? (s82(3)) of the GIPA Act. (It will be useful to include in your internal review application the Notice of Decision noting the section of decision to be reviewed). *

Applicant's signature *

Draw signature|Type signatureClear

Date *

3. Application Fee

This application has a cost of $40.00

A payment processing fee of 0.62% applies to all payments made via this service.

Payment *

4. Privacy Notice

In submitting this form, you consent to Council:

1. collecting your personal information as contained in the form; and

2. using the information for the purposes outlined in the form.

Providing your information is voluntary. Should you choose not to provide the information, Council is unable to process your application/request.

You may access any of your personal information that Council holds upon request.

Accept Privacy Policy *