FOR DEPARTMENTAL USE

Reference number:                                              

Request received by                                                                                                                                                  

(state rank, name and surname of information officer/deputy information officer) on

                                                                                              (date) at                                                                             (place) .

(a)

The particulars of the person who requests access to the record must be given below

(b)

The address and/or fax number in the Republic to which the information is to be sent, must be given.

(c)

Proof of capacity in which the request is made, if applicable, must be attached.

This section must be completed ONLY if a request for information is made on behalf of another person.

(a)

Provide full particulars of the record to which access if requested, including the reference number if that is known to you, to enable the record to be located.

(b)

If the provided space is inadequate, please continue on a separate folio and attach it to this form. The requester must sign all the additional folios.

(a)

A request for access to a record, other than a record containing personal information about yourself, will be processed only after a request fee has been paid.

(b)

You will be notified of the amount required to be paid as the request fee.

(c)

The fee payable for access to a record depends on the form in which access is required and the reasonable time required to search for and prepare a record.

(d)

If you qualify for exemption of the payment of any fee, please state the reason for exemption.

If you are prevented by disability read, view or listen to the record in the form of access provided for in 1 to 4 below, state your disability and indicate in which form the record is required.

Disability:

Form in which record is required:

Mark the appropriate box with an X.

NOTES:

(a)

Compliance with your request for access in the specified form may depend on the form in which the record is available.

(b)

Access in the form requested may be refused in certain circumstances. In such a case you will be informed if access will be granted in another form.

(c)

The fee payable for access to the record, if any, will be determined partly by the form in which access is requested.

1.        If the record is in written or printed form:

copy of record*

inspection of record

2.        If record consists of visual images—

(this includes photographs, slides, video recordings, computer-generated images, sketches, etc.):

view the images

copy of the images*

transcription of the images*

listen to the soundtrack (audio cassette)

transcription of soundtrack*

(written or printed document)

4.        If record is held on computer or in an electronic or machine-readable form:

printed copy of record*

printed copy of information derived from the record*

copy in computer readable form* (stiffy or compact disc)

*If you requested a copy or transcription of a record (above), do you wish the copy or transcription to be posted to you?

Postage is payable

YES

NO

Note that if the record is not available in the language you prefer, access may be granted in the language in which the record is available.

In which language would you prefer the record?                                                                            

You will be notified in writing whether your request has been approved/denied. If you wish to be informed in another manner, please specify the manner and provide the necessary particulars to enable compliance with your request.