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 (YYYY-MM-DD)

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 (YYYY-MM-DD)

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