ANNEXURE B IN TERMS OF NOTICE 187 OF GOVERNMENT GAZETTE OF 15 FEBRUARY 2002
REQUEST FOR ACCESS TO RECORD OF PUBLIC BODY
(Section 18(1) of the Promotion of Access to Information Act, 2000 (Act No. 2 of 2000))
A. Request record
B. Particulars of public body
The Information Officer / Deputy Information Officer
C. Particulars of person requesting access to the record
(a) The particulars of the person who requests access to the record must be recorded below.
(b) Furnish an address and/or fax number in the Republic to which information must be sent.
(c) Proof of the capacity in which the request is made, if applicable, must be attached.
Full names and surname
Capacity in which a request for information on behalf of another person is made
D. 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.
If this section do not apply to you please insert n/a in areas marked as Required.
Full names and surname
E. 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 THIS FORM IS PRINTED OUT AND SUBMITTED MANUALLY:
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.
Description of record or relevant part of the record
Any further particulars of record
(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 therefore.
Reason for exemption from payment of fees
G. 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.
Form in which record is required
Select the appropriate option.
(a) Your indication as to the required form of access depends 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 (includes photographs, slides, video recordings, computer-generated images, sketches, etc.)
View the images
Copy of the images
Transcription of the images
3. If record consists of recorded words or information which can be reproduced in sound
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
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
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 thereof 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
this 22 May 2013
Full name of requester / person on whose behalf request is made
I. Web form security
Security check for form abuse
Please enter the code shown: