FORM C
REQUEST FOR ACCESS TO
RECORD OF PRIVATE BODY
(Section 53(1) of the
Promotion of Access to Information Act, 2000
(Act No. 2 of 2000)
[Regulation
10]
A. Particulars
of private body
The Head:
B. Particulars of person requesting access to the record
(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 the capacity in which the request is made, if applicable, must be attached.
Full names and surname:
Identity number:
Postal address:
Fax number:
Telephone number:
E-mail address:
Capacity
in which request is made, when made on behalf of another person:
C. Particulars of person on whose behalf request is made
This section must be completed ONLY if a request for
information is made on behalf of another person.
Full
names and surname:
Identity number:
D.
Particulars of record
(a) Provide full particulars of the record to which
access is 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.
1 Description of record or relevant part of the record:
2 Reference number, if available:
3 Any further particulars of record:
E. Fees
(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.
Reason for
exemption from payment of fees:
F. Form
of access to record
If you are
prevented by a disability to read, view or listen to the record in the form of access provided for in 1 to 4 hereunder, state your disability and indicate in which form the record is required.
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Disability: Form
in which record is required:
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Form in which record is required
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Mark the appropriate box with an
X.
NOTES:
(a) Compliance with your request 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
for the record, if any, will be determined partly by the form in which access
is requested.
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1. If
the record is in written or printed form:
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copy of record*
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inspection of
record
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2. If record
consists of visual images
this includes photographs, slides,
video recordings, computer-generated images, sketches, etc)
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view the
images
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copy of the
images"
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transcription
of the
images*
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3. If record consists of recorded words or
information which can be reproduced in
sound:
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listen to the
soundtrack
audio cassette
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transcription
of soundtrack*
written or
printed document
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4.
If record is held on computer or in an electronic or machine-readable
form:
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printed copy
of record*
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printed copy
of information
derived from
the record"
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copy in
computer readable form*
(stiffy or compact disc)
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'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.
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YES
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NO
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G Particulars of right to be exercised or protected
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.
1. Indicate
which right is to be exercised or protected:
2. Explain
why the record requested is required for the exercise or protection of the
aforementioned right:
H. Notice of decision regarding request
for access
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.
How would you prefer to be
informed of the decision regarding your request for access to the record?
Signed at
. This
day of
.20
SIGNATURE OF
REQUESTER / PERSON ON
WHOSE BEHALF
REQUEST IS MADE
