Appendix 1

PRESCRIBED FORM TO BE COMPLETED BY A REQUESTER

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]

Particulars of private body

The Head:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

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:

_________________________________________________________________________________