CSIS Consent Form. Input details, print and hand sign!
INDIVIDUAL CONSENT FORM TO DISCLOSE
PERSONAL INFORMATION TO A DESIGNATED THIRD PARTY
I hereby authorize _______________________________________________________________
to act on my behalf for the purposes of requests for information to the Canadian Security
Intelligence Service under the
Access to Information Act
, which includes
information pertaining to me.
I further authorize the Canadian Security Intelligence Service to disclose to:
personal information pertaining to me be released through my request dated _________________
I understand the information may be subject to exemption in accordance with the aforementioned
This authorization is valid for two years from the date signed below.
This ________________ day of ________________ of __________________________
Print name: _________________________________________
Date of birth: _______________________________________