Fillable AUTHORIZATION FOR DISCLOSURE OF PERSONAL INFORMATION TO A (British Columbia Institute of Technology)

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AUTHORIZATION FOR DISCLOSURE OF PERSONAL INFORMATION TO A (British Columbia Institute of Technology)

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FOI-2 (2016:05)
AUTHORIZATION FOR DISCLOSURE OF PERSONAL
INFORMATION TO A THIRD PARTY
Information Access and Privacy
3700 Willingdon Avenue, Burnaby, BC, Canada V5G 3H2
T 604.432.8508 F 604.434.1585 E FOI@bcit.ca W bcit.ca/iap
I, ____________________________________________________________________________ authorize BCIT to disclose my personal information to:
Name of Third Party Title
Organization / Company Phone/Cell
I authorize BCIT to disclose the following information (Please be specific):
I understand that when disclosed, the information in these records will be used for the following purpose:
This consent becomes eective from the following date (dd/mm/yy)
Signature BCIT ID*
Date (dd/mm/yy)ww Date of Birth*
Day Phone* Email
This form meets the requirements for consent in the
Freedom of Information and Protection of Privacy Act
, RSBC 1996 c. 165 (“FIPPA”) and
Regulations. You may rescind or amend your consent in writing at any time, except where action has been taken in reliance of this authorization.
* This information must be included. The BCIT ID and DOB are required to confirm your identity.
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AUTHORIZATION FOR DISCLOSURE OF PERSONAL INFORMATION TO A (British Columbia Institute of Technology)

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Completed 30 January 2021

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