Form 1
Application for Access to a Record Province of Nova Scotia
Freedom of Information and Protection of Privacy Act
Subsection 6(1)

TO:  	

(Address to the Deputy Minister or senior administrative officer of the public body where the record is filed or deposited.)

1.	This is an application pursuant to the Freedom of Information and Protection of Privacy Act for access to (check one):

 		(a)
 		(b)
 		(c)

applicant's own personal information; or other information; or
both applicant's own personal information and other information.

2.	I am applying for access to the following record:
(Below, identify the material applied for precisely by including such particulars as the specific event or action to which it refers, the date of the record or the date or period to which it relates, the type of record (document, report, letter et cetera), names of department personnel who prepared or may have knowledge of the information, or citations to newspapers or publications which are known to have referred to the record.)

3.	I wish to (check one):

(a)

(b)

examine the record; or
receive a copy of the record.

4.	I understand that I may be required to pay a fee before obtaining access to the record. Date:  	
Signature of Applicant:

Print Full Name of Applicant:

Mailing Address of Applicant:	 	
(Street/Apartment No./R.R. No.)

(Community/County)

(Postal Code)
Telephone Numbers of Applicant:	 	
(Residence) / (Business)
Fax Number of Applicant:

Request to Waive Fees
I hereby request to be excused from paying fees related to the above application because:
(a)	I cannot afford to pay fees; or
(b)	(specify any other reason)  	

Date Received  	

For office use only
Application No.