Please use this form only if you are a Requesting Authority making an Emergency Request in accordance with the PROXIMA BETA Law Enforcement Data Request Guidelines.

Requested Game:


Requesting Authority:


Request Contact’s Details:

(i) Requesting Authority

(ii) Agent Name and Rank

(iii) Badge/Identification Number:

(iv) E-mail Address (must be from the Requesting Authority’s email domain address):

(v) Direct phone number

(v) Address



Detailed description of the nature of the emergency and why the threat is imminent (i.e. description of why there is an imminent emergency involving risk of death, serious physical injury to a person or any risk of harm to a child; and why the normal legal process for disclosure would be insufficient):


The identity of the person who is in danger of death or serious physical injury, or the child who is at imminent risk of harm:



The user to which the Request relates (including their identification/ IP Address / account details):



List and specific type of data being requested.


Purpose for which each type of requested data is to be used in relation to the Request.


Why is the requested type of data considered necessary for the identified purpose(s).


Detailed description of specific data being requested from us regarding the relevant user / account and why that information is necessary to prevent the emergency:



The basis of the Request, including the provisions of any specific legislation being relied upon and relevant supporting documentation evidencing authorisation to make such Request.


Request response date:



I declare that to the best of my knowledge, all information contained in this Emergency Disclosure Request Form is true and correct.


_____________________________                               _________________________________________________________

Signature and identification number                                                     Date