WVRFOR556 Freedom of Info

8/4/05

3:30 PM

Page 1

FREEDOM OF INFORMATION REQUEST FORM

This form is designed to assist you to make a valid FOI request under the Freedom of Information Act 1982. More information is available at our website (www.workcover.vic.gov.au). Contact us at foi@workcover.vic.gov.au PLEASE NOTE: If you seek documents relating to your WorkCover claim please write directly to your employers WorkCover agent using the Access to WorkCover Claim Information Request Form. No fee attaches to such requests. Applicant Full name or Firm name

Information Request Please provide as much information as possible about the documents to which you seek access. This will assist us to locate all relevant information.

For attention of:

Title Mr

Mrs

Ms

Dr

Other (please specify)

Postal address Authority to release documents to representative. If this application is for personal information and is made by a representative of that person, please complete this Authority. I, (Name of person whose information is requested) Applicants signature of (Address) Date

Telephone

Facsimile

/
hereby authorise the release of all documents relating to this Freedom of Information request, directly to my representative (Representative name)

Please return completed form to: The FOI Officer, Victorian WorkCover Authority, GPO Box 4306 Melbourne Victoria 3001. Application Fee Make cheques out to Victorian Workcover Authority. Have you attached the application fee? Yes No I seek a waiver of the fee on the grounds of financial hardship and attach supporting evidence (attach Health Care Card, Pension Card or other).

of (Representatives contact address)

Please Sign

FOR556/02/03.05