KP90 F10

							                     Freedom of Information Request
                          Charges - Credit Card Payment Form

 Applicant:
 Applicant’s Postal Address:




 Applicant’s Contact Phone                Ph:
 Numbers:                                 Mobile:
 Applicant’s Email Address:

 FOI Reference (if known):                G
 Payment for:                                   Deposit - charges
 (Please tick one box only)                     Balance - charges
                                                Full payment - charges

NB: Charges imposed by the APVMA to process your FOI Request are excluded from GST under A New
Tax System (Goods and Services Tax) (Exempt Taxes, Fees and Charges) Determination 2011 (No. 1),
and will not be issued on a tax invoice.

Enter your credit card details, sign below and return via any of the following methods:

Email: foi@apvma.gov.au
Fax:    02 6210 4787
Post:   Freedom of Information & Privacy Coordinator
        APVMA
        PO Box 6182
        Kingston ACT 2604




Card type (circle one):   Visa        Mastercard          Diners Club        American Express

Card Number:              ____ ____ ____ ____

Expiry:                   __/____

Amount:                   $

Name on Card:             ___________________________

Signature:                ___________________________

                                  18 Wormald Street, Symonston ACT 2609
                                 PO Box 6182, Kingston ACT 2604 Australia
                                 Tel: +61 2 6210 4785 Fax: +61 2 6210 4787
                                  www.apvma.gov.au ABN 19 495 043 447
 KP90_F10                                                                                 Version 2