Personal Information Revision/Access Request Form

Title

First Name

Last Name

Other names you may have or currently use (if applicable)

Mailing Address

City

Province

Postal Code

Country

Daytime Phone Number

Alternative Phone Number

Fax

Email

Request for

Access to own personal information
Correction of own personal information

Date of Birth

Department/Unit that has custody of the record (if known)

Record(s) you wish to access (Provide as much detail as possible)

Note: University Secretariat staff may contact you for clarification if more detailed information is needed to process your request.

How would you prefer to receive the records requested?

Please Select... Examine Original Receive Copy Electronic Copy

Method to receive copies

Please Select... By Email By Fax By Postal Service

By filling in your name below and clicking "Send Request" you are signifying that you are submitting a request for your personal information or corrections to your personal information under the Right to Information and Protection of Privacy Act.

Please confirm your request by typing in your name and date in the fields below:

Full Name

Date