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

or

Privacy Act

, which includes

personal

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 _________________

Y-M-D

I understand the information may be subject to exemption in accordance with the aforementioned

Acts.

This authorization is valid for two years from the date signed below.

Dated at

_____________________________________________________________________

This ________________ day of ________________ of __________________________

date

month

year

Print name: _________________________________________

(first name)

_________________________________________

(last name)

Date of birth: _______________________________________

Y-M-D

Signature:

________________________________________

LC4197_e (2018/05)