PRIOR -rc o2oI7 CO PIRED I>Ca lel%n- 46 A Reakr vF POtAC---E -77024e-mJG CAFFLICATION FOR ACCESS TO SAPOL RECORDS) (FREEDOM OF INFORi ATIO:. ACT -SECTION 13i A FEE MUST ACCOMPANY THIS APPLICATION PROOF OF IDENTITY IS REQUIRED • Please use BLOCK letters • If you need help, ask our staff DETAILS OF PERSON A Pia yiNG FOR ACCESS TO SAPOL RECORDS Name: (mr, wr, mat M$ M'S PE-efk<Le -7\ '‘''iCC:t-t- Li O1€ C.911)sa- DOB ani taws tionstis) Residential Address: ___, Postcode. _ Telephone: (Home) (Work) (Mobile) Fax __ _. __ COMPLETE 1 HIS SECTION TO HAVE YOUR CORRESPONDENCE I: :IR =WED TO ANOTHER PERSON Company and contact name: _ .. . __. Company Actress: Postcode: Telephone: Fax: DETAILS OF REQUEST Please descaibe clearly what you want and include names of any other person(s) involved in incident, data, times, locations and any other information width VA help to identify the document(s). Your personal Involvement ill this requellt mg be included. • tTnTe-i4ENTS be Wit-rivecse:s Net 4te 1•4 ftELPM0 f —to CHARGES •?teensy% of PO t t GE. OPFIGERS INqoeVec) IN -TI-ie Vitz.fteSTS etve. i T4's Ettsh ete4 5 • RFc_nst3F-Cs Inrret‘sr i rya e", • PCiAsE caE ern -Act-ter) • Rftnantn F'I4 o n)er cva as Ui oeo FOOT fgie PO%) 0 RELCISS)FC1 t c,-rp--Er,Nep.rn or a r..)-refk .4 i SAS IN ResrrioN it M -i5ecr Ree0FC' FEES & CHARGES (thegar- — le he made payable to South Australia Poi., • .;,:, Pt.H .• - t Attached is a cheque / cash for $ beng for the fee payable upon lodgement of this application I understand that I may be required to pay further orocessng charges and that I will be supplied with a statement of charges if appropriate. /I you wish to claim a reduction or waiver of fees, complete the following section and attach copies or supporting documents to this form (e.g. concession card) l am requesting a 0 reduction Swawer in fees and charges Specify reasons) for claiming exemption: t--1EFIL.TH cF,RE °IRO -