GIPA Decision Internal Review Application

This form should be used if you wish to apply for internal review of a decision made under the Government Information (Public Access) Act 2009 (GIPA Act). You must lodge this form with us within 20 working days after notice of the decision was given to you.

A fee of $40 applies to the application – payment can be made online through Western Sydney University’s Payments facility – Office of Governance Services – Internal Review Fee

If you need help in filling out this form, please contact the Right to Information Officer rti@westernsydney.edu.au.

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

Applicant Details

*Last name
Title
*Other name/s
*Postal address
*Postcode
*Day-time telephone
Facsimile
*Email
*I agree to receive correspondence to the above email address	Yes No

Application Fee

*Has the prescribed application fee been paid?	Yes No
Payments Receipt Number

Decision Details

*Would you like the entire decision reviewed?	Yes No
If yes – what is the decision to be reviewed (s80 of the GIPA Act)?
If no – what particular aspect of the decision would you like reviewed (s82(3)) of the GIPA Act. Please include the Notice of Decision in your internal review application
*Date of decision
*File reference
*Date

GIPA Decision Internal Review Application

Applicant Details

Application Fee

Decision Details

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