PROTECTED WHEN COMPLETED -
B
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CONSENT FOR AN ACCESS TO INFORMATION AND PERSONAL INFORMATION REQUEST
Complete this form if you authorize the Access to Information and Privacy (ATIP) Division at Citizenship and Immigration Canada (CIC) to
release your personal information to someone other than yourself.
Please be advised that you must submit a separate consent form for each individual in your file over the age of 18 if you wish to receive their
information as well.
SECTION A -
You must clearly write your name and date of birth
Your full name
Family name (surname)
Given name(s)
Date of birth (YYYY-MM-DD)
Signature
Date (YYYY-MM-DD)
SECTION B -
If you are also seeking the information of your spouse or
common-law partner in your ATIP request, you must indicate their name and signature
Your spouse or common-law partner's full name (if applicable)
Given name(s)
Signature
Date (YYYY-MM-DD)
SECTION C -
You must write your designated individual's contact information
Given name(s) Rajni
Business or Organization Name (if applicable)
Immigration Consultants of Canada Regulatory Council (ICCRC) number (if applicable) E-mail address: 
4
I authorize CIC to release my personal information to the individual named above by ►
Mail
Email
SECTION D -
If the applicant is under 18 years of age, the parent or guardian must complete this section
5
Name of parent or guardian (please print)
Relationship
Signature
Date (YYYY-MM-DD)
NOTE: This consent is only valid for one time use. A new consent form must be filled out for every request that you submit.
The information you provided on this form is collected under the authority of the
Access to Information Act
and the
Privacy Act
and will be
used to administer these acts, as well as to process and respond to requests. This information may also be used during consultations with
other government institutions during investigations by the Office of the Information Commissioner and the Office of the Privacy Commissioner
and during court reviews. It will be retained in Personal Information Bank CIC PSU 901 – Access to Information and Privacy Requests. It may
also be shared with other organizations in accordance with the consistent use of information as per paragraph 8(2) of the
Privacy Act
.
Pursuant to the
Access to Information Act
and the
Privacy Act
, individuals have the right to the protection of and access to their personal
information. Details of these matters are available at
infosource.gc.ca
and through the
Citizenship and Immigration Canada web site
.
IMM 5744 (10-2014) E
1
2
Family name (surname)
3
Family name (surname) Kalia
