PERSONAL INFORMATION

Full Names

Identity Number

Capacity in which request is made (when made on behalf of another person)

Postal Address

Street Address

E-mail Address

Contact Numbers

Tel. (B):

Facsimile:

Cellular:

Full names of person on whose behalf request is made (if applicable):

Identity Number

Postal Address

Street Address

E-mail Address

Contact Numbers

Tel.(B)

Facsimile

Cellular

PARTICULARS OF RECORD REQUESTED

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. (If the provided space is inadequate, please continue on a separate page and attach it to this form. All additional

pages must be signed.)

Description of record or relevant part of the record:

Reference number, if available

Any further particulars of record

TYPE OF RECORD

(Mark the applicable box with an "X")

Record is in written or printed form

Record comprises virtual images (this includes photographs, slides, video recordings, computer-generated images, sketches, etc)

Record consists of recorded words or information which can be reproduced in sound

Record is held on a computer or in an electronic, or machine-readable form

FORM OF ACCESS

(Mark the applicable box with an "X")

Printed copy of record (including copies of any virtual images, transcriptions and information held on computer or in an electronic or machine-readable form)

Written or printed transcription of virtual images (this includes photographs, slides, video recordings, computer-generated images, sketches, etc.)

Transcription of soundtrack (written or printed document)

Copy of record on flash drive (including virtual images and soundtracks)

Copy of record on compact disc drive(including virtual images and soundtracks)

Copy of record saved on cloud storage server

MANNER OF ACCESS

(Mark the applicable box with an "X")

Personal inspection of record at registered address of public/private body (including listening to recorded words, information which can be reproduced in sound, or information held on computer or in an electronic or machine-readable form)

Postal services to postal address

Postal services to street address

Courier service to street address

Facsimile of information in written or printed format (including transcriptions)

E-mail of information (including soundtracks if possible)

Cloud share/file transfer

PARTICULARS OF RIGHT TO BE EXERCISED OR PROTECTED

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

Indicate which right is to be exercised or protected

Explain why the record requested is required for the exercise or protection of the aforementioned

right:

FEES

1. A request fee must be paid before the request will be considered.

2. You will be notified of the amount of the access fee to be paid.

3. 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.

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

exemption

Reason

Postal address

Facsimile

Electronic communication

(Please specify)

Reference number:

Request received by:

(State Rank, Name and Surname of Information

Officer)

Date received:

Access fees:

Deposit (if any):