APPLICATION FOR
Access to Government Information
Government Information (Public Access) Act 2009
OFFICE USE ONLY
Reference No.
About this form
Before completing this form, please consider requesting access to government informal informally via email at
xxxx@xxxxxxxx.xxx.xxx.xx. There is no application fee associated with an informal application.
Use this form to apply for formal access to government information under the Government Information (Public Access) Act
2009 (the GIPA Act). For further information, please contact Governance on 9083 8000 or visit our website at
https://www.waverley.nsw.gov.au/council/access_to_information.
Applicant details
Date of Application:

Applicant’s Reference:
Title:
☐ Mr
☐ Mrs
☐ Ms
☐ Other

Given Name/s:
Family Name:
Company Name (if applicable):

ABN/ACN (if applicable):

Mailing Address:

Suburb:
State:
Post Code:
Email Address:

Daytime Telephone No. (Home/Work):

Mobile No:
Please attach proof of your authorisation to act on the person’s behalf, such as legal documentation in support of your
authority (for example: a client agreement if you are a solicitor) or written authorisation for the person concerned.

CM reference: D24/121060  |  Last updated: 31/10/2024
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Postal address
Waverley Council Service Centres
W waverley.nsw.gov.au
PO Box 9, Bondi Junction NSW 1355
Bondi Junction Customer Service Centre, 55 Spring St, Bondi Junction NSW 2022
E xxxx@xxxxxxxx.xxx.xxx.xx
ABN 12 502 583 608
Bondi Pavilion Customer Service, Queen Elizabeth Drive, Bondi Beach NSW 2026
T (02) 9083 8000

You can contact us through the National Relay Service
Translating and Interpreting Service (TIS)
TTT/Voice Calls
Speak & Listen
if you are deaf or have a hearing or speech impairment.
131 450
133 677
1300 555 727

Waverley Council
Application for Access to Government Information
Government 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, Council may refuse to process your application.

Third party consultation
Council may need to consult with other parties about the release of the information that you have requested. Do you object
to your name being released to these parties?
☐ No, I have no objection to the release of my name.
☐
■ Yes, I object to the release of my name.
Form of access
How do you wish to access the information?
☐
■ A copy of the document(s)
☐
■ Inspect the document(s)
☐ Access in another way (please specify):

Disclosure log
If the information sought is released to you and would be of benefit to other members of the public, details about your
application (other than your personal information) may be recorded in Council’s ‘disclosure log’. This is published on
Council’s website.
Do you object to this?
☐ Yes
☐
■ No
Application fee
Payment of the $30 application fee can be made by:
•
Visa/Mastercard/Amex (0.8% surcharge applies)
•
Cheque/Money Order to PO Box 9, Bondi Junction 1355
•
Eftpos/Cash at the Customer Service Centre

CM reference: D24/121060  |  Last updated: 31/10/2024
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You can contact us through the National Relay Service
Translating and Interpreting Service (TIS)
TTT/Voice Calls
Speak & Listen
if you are deaf or have a hearing or speech impairment.
131 450
133 677
1300 555 727

Waverley Council
Application for Access to Government Information
Declaration
I declare that the information given is true and correct.
Applicant’s Signature

  Date
/
/

How to lodge this application
You can lodge your completed application form and any required supporting documents:
Email:
xxxx@xxxxxxxx.xxx.xxx.xx
Mail:
Waverley Council PO Box 9 Bondi Junction NSW 1355
With payment via cheque or money order (do not send cash).
In person:
At any of Council’s Customer Service Centres:

•
Bondi Junction Customer Service Centre, 55 Spring St, Bondi Junction NSW 2022
•
Bondi Pavilion Customer Service (Welcome Centre), Queen Elizabeth Drive, Bondi Beach NSW 2026
Privacy notice
Waverley Council (55 Spring Street, Bondi Junction NSW 2022) is collecting and holding your personal information for the
purpose of processing your request or application. The intended recipients of your personal information are Council officers
and other service providers necessary to process your request or application, if applicable. We will not disclose your
personal information to anybody else unless you have given consent, or we are authorised or required to do so by law. If you
do not provide your personal information, we may be unable to process your request or application. To access or correct
your personal information, please contact xxxx@xxxxxxxx.xxx.xxx.xx or call 9083 8000. For further details on how Council
manages your personal information, please refer to the Privacy Management Plan on our website:
waverley.nsw.gov.au/privacy
Copyright disclaimer
If you copy, reproduce, republish, transmit or distribute any plans or other documents subject to copyright, contrary to the
Copyright Act 1968 (Cth), you will be taken to have indemnified Waverley Council against any claim or action in respect of
breach of copyright.

OFFICE USE ONLY
Receipt No
Date
$

CM reference: D24/121060  |  Last updated: 31/10/2024
3/3
You can contact us through the National Relay Service
Translating and Interpreting Service (TIS)
TTT/Voice Calls
Speak & Listen
if you are deaf or have a hearing or speech impairment.
131 450
133 677
1300 555 727

Document Outline