NORTHERN TERRITORY POLICE REQUEST FOR ROAD TRAFFIC ACCIDENT INFORMATION TO: Accident Records Clerk Police Ref: NT Police, Fire & Emergency Services PO Box 39764 Our Ref: WINNELLIE NT 0821 Date: ______/______/_________ Telephone: 08-89223510 Fax: 08-89223357 I/We (name & address of applicant) ________________________________________________________________________ _____________________________________________________________________________________________________ Wish to apply for information in relation to Motor Vehicle Accident, details of which are as follows: Date of Accident: _______________________________________________________________________________________ Location of Accident: ____________________________________________________________________________________ Driver/s or Pedestrian/s: _________________________________________________________________________________ Vehicle Registration No/s: ________________________________________________________________________________ Member/Police Station reported to: _________________________________________________________________________ I/We request: (Fees $28.00 Search Fee plus 55c per photocopy page) [ ] A copy of Road Accident Report [ ] A copy of a Statement (Authority for release to me is attached) [ ] A copy of Blood Alcohol Certificate (Authority for release to me is attached) [ ] Permission to Interview Investigating Police Officer ($28.00 per half hour or part thereof). Establishment of Interest (applicant to state reason and the basis on which a bonafide interest in the information is claimed). _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Signature of applicant: _______________________________________ Date: _______________________________ FOR ACCIDENT RECORDS USE ONLY To Accident Records Receipt No. Amount Received Copy Supplied: Northern Territory Police, Fire and Emergency Services (NTPFES) is collecting information on the application form for Road Traffic Accident Information. The collection of this information is authorised under the provisions of the Police Administration Act. Failure to provide this information may result in your application not being processed. You can access your personal information provided on this form. If you have any queries or wish to access this information please contact NTPFES by phoning (08) 89223242.
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