FREEDOM OF INFORMATION
AND PROTECTION OF PRIVACY
SECTION 1 – ABOUT YOU
Mr. Mrs. Dr. Last Name:
Ms. Miss N/A
Daytime Phone #: Evening Phone #:
SECTION 2 – ABOUT YOUR REQUEST
Provide a detailed description of requested records, personal information, or personal information to be
corrected. If you are requesting access to, or correction
of, your own personal information, please include your date
of birth and identify the Personal Information Bank (PIB) or record containing the personal information, if known, as
well as the last name appearing on the records if different from above.
Name of Department request made to: PIB:
Access to General Records
Access to Own Personal Information
Correction to Own Personal Information
Last name appearing on records: Same as above
Date of birth (if applicable):
Note: If you are seeking a correction to personal information, please indicate the desired correction and, if appropriate, attach any
support documentation. You will be notified if the correction is not made and you may request that a statement of disagreement be
attached to your personal information.
Preferred method of access to records:
Examine Original Receive Copy
SECTION 3 – ABOUT THE PROCESS
Each separate request must be accompanied by the $5.00 application fee – cheques or money orders should
be made payable to the University of Guelph.
All requests for personal information will require proof of identification before information can be released.
Personal information contained on this form is collected pursuant to Freedom of Information and Protection of Privacy
legislation and will be used for the purpose of responding to your request. Questions about this collection should be
directed to email@example.com, by phone at (519) 824-4120 ext. 56760 or by mail at:
University of Guelph, 50 Stone Road East, UC 401, Guelph, Ontario, Canada, N1G 2W1
SECTION 4 – YOUR SIGNATURE
Day: Month: Year: