FOR DEPARTMENTAL USE Reference number: _______________ Request received by __________________________________________________(state rank, name and surname of information officer/deputy information officer) on _________ _________(date) at ____________________________________(place). Request fee (if any): R……………………………. Deposit (if any): R……………………………. Access fee: R……………………………. ___________________________________ SIGNATURE OF INFORMATION OFFICER/DEPUTY INFORMATION OFFICER

A. Particulars of public body
The Information Officer/Deputy Information Officer:
MR RIAAN STRYDOM
RKS COMPUTER SOLUTIONS
P O BOX 2765
MIDDELBURG, 1050
SOUTH AFRICA
TELEPHONE NO: +27 (0) 82 556 2022
FAX NO: +27 (0) 86 604 9696
email:onlineshop@rkscomputersolutions.com

B. 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) Furnish an address and/or fax number in the Republic to which information must 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: _________________

______________________________________________________________________________

C. Particulars of person on whose behalf request is made

This section must be completed ONLY if a request for information is made on behalf of another person.

Full names and surname: __________________________________________________________________________________________

_______________________________________________________________________________

Identity number: ___________________ _____________________________________________

D. Particulars of record

(a) Provide full particulars of the record of which access is requested, including the

reference number if that is known to you, to enable the record to be located.

(b) If the provided space is inadequate please continue on a separate folio and attach

it to this form. The requester must sign all the additional folios.

1. Description of record or relevant part of the record: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ E. Fees (a) A request for access to a record, other than a record containing personal information about yourself, will be processed only after a request fee has been paid. (b) You will be notified of the amount required to be paid as the request fee. (c) The fee payable for access to a record depends on the form in which access is required and the reasonable time required for search for and prepare a record. (d) If you qualify for exemption of the payment of any fee, please state the reason