HomeMy WebLinkAboutFreedom of Information Request for Access to Records.pdfMicrosoft Word - Request Form_revised_2008-07-03.doc
YOUR NAME SURNAME FIRST NAME MIDDLE NAME YOUR ADDRESS STREET, APT., P.O. BOX, R.R. NUMBER(S) CITY/TOWN PROVINCE/COUNTRY POSTAL CODE YOUR CONTACT INFORMATION DAYTIME TELEPHONE NUMBER
( ) ALTERNATE NUMBER(S) ( ) ( ) DAYTIME FAX NUMBER ( ) E-MAIL ADDRESS DETAILS OF REQUESTED INFORMATION PLEASE DESCRIBE THE RECORDS YOU ARE REQUESTING. BE AS SPECIFIC AS POSSIBLE AS
THIS WILL ASSIST THE REQUEST PROCESS. IF KNOWN, SPECIFY ANY REFERENCE OR FILE NUMBER(S). IF INSUFFICIENT SPACE, PLEASE USE THE NEXT PAGE. YOU MAY MAKE A REQUEST FOR ACCESS TO RECORDS
WITHOUT USING THIS FORM PROVIDED YOU DO SO IN WRITING ARE YOU REQUESTING ACCESS TO ANOTHER INDIVIDUAL’S PERSONAL INFORMATION? ı YES ı NO IF YES, PLEASE ATTACH AS APPROPRIATE: (a) THAT
INDIVIDUAL’S CONSENT FOR DISCLOSURE OR (b) PROOF OF AUTHORITY TO ACT ON THAT INDIVIDUAL’S BEHALF DATE SIGNED PREFERRED METHOD OF ACCESS ı EXAMINE ORIGINAL RECORDS ı RECEIVE COPY OF
RECORDS YOUR SIGNATURE YR. MO. DAY FOR STAFF USE ONLY REQUEST NO. DATE RECEIVED DATE FOR RESPONSE PERSONAL INFORMATION REQUESTED ON THIS FORM IS COLLECTED UNDER THE FREEDOM OF INFORMATION
AND PROTECTION OF PRIVACY ACT AND WILL BE USED ONLY FOR THE PURPOSE OF RESPONDING TO YOUR REQUEST. FREEDOM OF INFORMATION & PROTECTION OF PRIVACY REQUEST FOR ACCESS TO RECORDS
DETAILS OF REQUESTED INFORMATION CONTINUED