Request for Access to Record of Private Body

A. PARTICULARS OF PRIVATE BODY

The Head:

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) The address and/or fax number in the Republic to which the information is to be sent must be given. (c) Proof of the capacity in which the request is made, if applicable, must be attached.

Name*

First Last

Postal Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Identity Number*

Telephone number

Fax number

E-mail address*

Enter Email Confirm Email

Capacity in which request is made, when made on behalf of another person

C. PARTICULARS OF PERSON ON WHOSE BEHALF THE REQUEST IS MADE

(a) The particulars of the person who requests access to the record must be given below. (b) The address and/or fax number in the Republic to which the information is to 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

First Last

Identity Number

D. PARTICULARS OF RECORD

(a) The particulars of the person who requests access to the record must be given below. (b) The address and/or fax number in the Republic to which the information is to be sent must be given. (c) Proof of the capacity in which the request is made, if applicable, must be attached.

1. Description of record or relevant part of the record*

2. Reference number, if applicable:

3. Any further particulars of 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 to search for and prepare a record. (d) If you qualify for exemption of the payment of any fee, please state the reason for exemption.

Reason for exemption from payment of fees

F. FORM OF ACCESS TO RECORD

If you are prevented by a disability to read, view or listen to the record in the form of access provided for in 1 to 4 hereunder, state your disability and indicate in which form the record is required.

Disability

Form in which record is required

Mark the appropriate box with an X.

Notes (a) Compliance with your request in the specified form may depend on the form in which the record is available. (b) Access in the form requested may be refused in certain circumstances. In such a case you will be informed if access will be granted in another form. (c) The fee payable for access to the record, if any, will be determined partly by the form in which access is requested.

1. If the record is in written or printed form:

2. If record consists of visual images (this includes photographs, slides, video recordings, computer-generated images, sketches, etc.):

3. If record consists of recorded words or information which can be reproduced in sound:

4. If record is held on computer or in an electronic or machine-readable form:

G. PARTICULARS OF RIGHT TO BE EXERCISED OR PROTECTED

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. Indicate which right is to be exercised or protected

2. Explain why the record requested is required for the exercise or protection of the aforementioned right

H. NOTICE OF DECISION REGARDING REQUEST FOR ACCESS

You will be notified in writing whether your request has been approved / denied. If you wish to be informed in another manner, please specify the manner and provide the necessary particulars to enable compliance with your request.

How would you prefer to be informed of the decision regarding your request for access to the records?

Consent*

I agree

Place*

City

Date*

Hitachi Construction Machinery

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