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Authority to Release Personal Information to a Designated Representative
The information you provide in this document is collected under the authority of Section 4 of the
Access to Information Act
and Section 12 of the
Privacy Act
for the purposes of
administering the
Access to Information Act
and/or
the Privacy Act
. The information may be disclosed to Citizenship and Immigration Canada (CIC) for the purposes of responding to
Access to Information and Privacy (ATIP) Requests.
Failure to provide the personal information requested may result in your request not being fulfilled.
Individuals have the right of access to and/or can make corrections of their
personal information under the
Privacy Act
.
The information collected is described within Info Source under the Access to Information and Privacy Personal Information Bank PSU
901 which is detailed at http://www.cbsa-asfc.gc.ca/.
By completing this form, you authorize the Canada Border Services Agency and Citizenship and Immigration Canada to release
information about you, to
your designated individual
.
If your spouse or common-law partner wishes to release information to the same designated individual, he or she
must
sign in the space provided.
Failure
to do so will not permit CBSA or CIC to release any of their information. Your dependent children who are 18 years of age or older must also sign this form
in the space provided if they wish to authorize CBSA to release their information to your designated individual.
Providing consent from all parties involved
will accelerate the processing of your request.
1 – Your declaration
I, the undersigned, understand the following statements, having asked for and obtained an explanation for every point that was not clear to me.
I authorize the CBSA and CIC to release my personal information and customs information to the individual named in Section 2;
This consent allows the disclosure of information related to me, or to my dependent children under 18 years of age;
Some information may not be released if it is subject to exemptions under the
Privacy Act, Access to Information Act, Customs Act
and any other relevant
legislation;
This authorization is valid for one year from the date appearing after my signature.
2 – Your designated individual's Information
Family name (Surname)
Given name
Address
City
Province/Territory
Country
Postal Code
Firm/organization
Email Address
Telephone number
Other Telephone number
Fax number
3 – Your Information
Family name (Surname)
Given name
Date of birth (YYYY-MM-DD)
Your Client ID number (if applicable)
Signature
Date
I wish to give consent to my designated individual only
Or
I wish to give consent to my designated individual's firm
4 – Other Individuals' Information (i.e.: spouse, adult family member, business partner - if applicable)
Family name (Surname)
Given name
Date of birth (YYYY-MM-DD)
Your Client ID number (if applicable)
Signature
Date
Relationship to applicant
I wish to give consent to my designated individual only
Or
I wish to give consent to my designated individual's firm
BSF745 E
5 –
Other Individuals Information (i.e.: spouse, adult family member, business partner - if applicable)
Family name (Surname)
Given name
Date of birth (YYYY-MM-DD)
Your Client ID number (if applicable)
Signature
Date
Relationship to applicant
I wish to give consent to my designated individual only
Or
I wish to give consent to my designated individual's firm
6 – Other Individuals Information (i.e.: spouse, adult family member, business partner - if applicable)
Family name (Surname)
Given name
Date of birth (YYYY-MM-DD)
Your Client ID number (if applicable)
Signature
Date
Relationship to applicant
I wish to give consent to my designated individual only
Or
I wish to give consent to my designated individual's firm