Waterloo Regional Police Service / Municipal Freedom of Information and Protection of Privacy Act
Please note: A $5.00 application fee is required for all requests. Additional processing fees may apply. This Access/Correction Request
will be processed in accordance with the time lines set out in the Municipal Freedom of Information and Protection of Privacy Act
(MFIPPA) and Regulations. The time line to respond to your inquiry begins with the receipt of the $5.00 application fee. Type or print
in CAPITAL LETTERS using black or dark blue ink.
PART A: To be completed in full by the Requester
Request for:
Access to General Records
Access to Own Personal Information
Correction to Own Personal Information
Name of Institution request made to:
Access to Information Unit
Waterloo Regional Police Service
PO Box 3070
200 Maple Grove Road
Cambridge, ON N3H 5M1
If request is for access to, or correction of, own personal records:
The last name appearing on the records
is same as below or
Surname (last name) Given name(s)
Date of Birth (YY/MM/DD) Contact Telephone Number Can a message be left at this number?
Yes No
Mailing Address
Number Street Apt. City Prov/Terr./State Postal/ZIP code
Detailed description of requested records, personal information or correction of personal information:
(If request is for correction of personal information, please indicate the desired correction and attach any supporting documentation)
The record(s) you requested may contain the personal information of individuals other than yourself.
Do you wish these individuals be contacted to try and obtain their consent to disclose their information?
If yes, do you consent to our releasing YOUR identity to the individuals we contact?
(You are not required to release your identity under MFIPPA)
Yes No
Yes No
Preferred method of access to records:
Receive copy
Examine Originals (on-site only)
Signature Date (YY/MM/DD)
Personal information contained on this form is collected under section 17 of the Municipal Freedom of Information and Protection of
Privacy Act and will be used to respond to your request. Questions about this collection should be directed to the Access to
Information Unit at 519-653-7700 extensions 8514 or email Please visit for more information.
PART B: For Police Use Only
Fee Received by: Date Received (YY/MM/DD) Request Number Comments