HTML version of the form: Authorizing a Personal Information Request to be Made on Your Behalf Form
Protected B (when completed)
Authorizing a Personal Information Request to be Made on Your Behalf Form
Individuals have a right of access to their personal information. Should you wish that someone else, known as the “authorized representative” to make a request for your personal information on your behalf, you must authorize them to do so in writing.
Please complete this form and submit it with a completed “Personal Information Request Form.” By signing this form, you authorize the institution to which this form is submitted to release your information to the authorized representative. This form must be signed and dated by the person giving the authorization. Only original handwritten signatures signed in blue ink or valid digital signatures will be accepted. Missing signatures may delay the processing of your request.
Privacy notice statement
The personal information provided on this form is collected and protected under the provisions of the Privacy Act. It is retained and used as described in Personal Information Bank PSU 901 by the institution to which this form is submitted. Any questions about the collection, use or disclosure of this information should be directed to the Access to Information and Privacy Coordinator of the institution to which this form is submitted. The information is used to process and respond to formal requests made under the Privacy Act, including subsequent requests for correction, complaints, investigations and judicial review when applicable. The information provided on this form is used to record authorization for an individual to make a request on your behalf, and for the institution to disclose personal information to an authorized representative in response to your personal information request. It is collected under the authority of sections8(1) and 13 of the Privacy Act. The requested information is required to validate your authorization request. Failure to provide this information may result in the inability to process your request. You have the right to the correction of, access to, and protection of your personal information under the Privacy Act. You have a right to complain to the Office of the Privacy Commissioner of Canada regarding the handling of your personal information request.
- I acknowledge the privacy notice statement above.
Subject of the personal information request
- Family Name (Surname):
- Given name(s):
- Current Address (address number, apartment number, street, city, province, postal code):
- Telephone, E-mail, Fax:
Information about authorized representative
- Family Name (Surname):
- Given name(s):
- Relationship to the Requester:
- Current Address (address number, apartment number, street, city, province, postal code):
- Telephone, E-mail, Fax:
Information about your request
- Government institution to which you are submitting the request:
- Please describe the request that you are providing authorization for:
Signatures
By signing this form, I am authorizing the following individual to make a Personal Information Request on my behalf. The institution that I submitted the request to may release my personal information to this individual. If I have also completed a consent form, I understand that any information about those individuals will also be released to the authorized representative.
Please Note
The consent is valid for one year from the date appearing next to both signatures. Please sign in blue ink.
- Requester Signature:
- Date (yyyy-mm-dd):
- Authorized representative Signature:
- Date (yyyy-mm-dd):
TBS/SCT 350-55E (Revised 07/2022)