Subject Access Request Form

ACCESS REQUEST FORM - RECORD OF PRIVATE BODY

(Section 53(1) of the Promotion of Access to Information Act, 2000 and Section 23 of the Protection of Personal Information Act of 2013)

 

NOTES FOR COMPLETING THE FORM:

  1. The Access Request Form must be completed in full.
  1. Proof of identity is required to authenticate the identity of the Attach a copy of the requester’s identification document.
  1. Type or print in BLOCK LETTERS an answer to every 
  1. If a question does not apply, state “N/A”.
  1. If there is nothing to disclose in reply to a question, state “nil”.
  1. When there is insufficient space on a printed form, additional information may be provided on an attached folio, and each answer on such folio must reflect the applicable
  • Particulars of the organisation and their Information:

        Karin Wood, Cape Island Designs (Pty) Ltd, info@capeisland.co.za

  • Particulars of Requester (if natural person)

Full names and surname: ........................................................................................................

Identity number: .......................................................................................................................

Postal adress:........................................................................................................................

Telephone number:.....................................................................................................................

Email address:......................................................................................................................

Capacity in which request is made, when made on behalf of another person:

...................................................................................................................................

 

  • Particulars of Requester (if a legal entity)

Name: ........................................................................................................

Registration number: ......................................................................................................................

Postal adress:........................................................................................................................

Telephone number:.....................................................................................................................

Email address:......................................................................................................................

 

  • Particulars of person on whose behalf request is made 

Full names and surname: ...........................................................................................................

Identity number: ............................................................................................

 

  • Particulars of record requested 
  1. Description of record or relevant part of the record:
  1. Reference number, if available:
  1. Any further particulars of record
  • Fees

 

Reason for exemption from payment of fees:

Form of access to record

 

  1. If the record is in written or printed form:

Copy of record

 

Inspection of record

 

 

  1. If record consists of visual images

(photographs, slides, video recordings, computer-generated images, sketches, etc):

view the images copy of

the images

the images

 

transcription of

 

 

  1. If record consists of recorded information that can be reproduced in sound:

listen to the soundtrack (audio cassette)

 

transcription of soundtrack* (written or printed document)

 

 

  1. If record is held on computer or in an electronic or machine-readable form:

printed copy of record

 

printed copy of copy information derived from record

 

in computer readable form

 

If you are requesting a copy or transcription of a record (above), do you wish the copy or transcription to be posted to you? Postage is payable

 

Yes:

No:

 

  1. In the event of disability

Disability:

Form in which record is required:

 

  1. Particulars of right to be exercised or protected
  1. Indicate which right is to be exercised or protected: 
  1. Explain why the record requested is required for the exercise or protection of the aforementioned right:
  1. Notice of decision regarding request for access

 

How would you prefer to be informed of the decision regarding your request for access to the record?

  

Signed at                                    on this                 day of                               20      

  

SIGNATURE OF REQUESTER/ PERSON ON WHOSE BEHALF THE REQUEST IS MADE