J:\STUDENT\GraduationandPublications\Publications\For m s\ConsentforAuthorizedRepres entative08/2016
ConsentforAuthorizedRepresentative
Registrar&EnrolmentServices
STUDENTINFORMATION
LANGARAID:_________________________________________DATEOFBIRTH(MM/DD/YYYY):___________________________
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LEGALSURNAME:_____________________________________LEGALFIRSTNAME:_____________________________________
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REPRESENTATIVEINFORMATION
FULLNAMEOFPERSON/AGENCY:_______________________________________________________________________________
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RELATIONSHIP:_______________________________________EMAIL*:______________________________________________
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*Informationwillonlybesharedwiththisrepresentativeinpersonand/orbyemail.Ifyoudonotwishforinformationtobe
sharedbyemail,pleaseleavethisfieldblank.Emailinquirieswillonlyberespondedtoifsentfromthisaddress.
Thiswaiverwillbevalidforthefollowingperiod,oruntilIrevokeauthority:
From:_______________________________________________To:__________________________________________________
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STUDENTINFORMATION
Iauthorizetheperson/agencystatedaboveaccesstothefollowinginformation:
Academicstanding
Applicationstatus
Finalgrades
Graduationrequirements
Registrationinformation(includingcurrentregistrationstatus)
Specialneedsdocumentationordisabilityaccommodations
Other(specify):___________________________________
FINANCIALINFORMATION
Iauthorizetheperson/agencystatedaboveaccesstothefollowinginformation:
Studentaccountbalance
Studentawards
Studentloaninformation
Tuitionandfeesassessment
Other(specify):___________________________________
STUDENTTRANSACTIONS
Iauthorizetheperson/agencystatedabovetocarryoutthefollowingtransactionsonmybehalf:
Ordertranscripts,confirmationofenrolmentletters,RESPforms,etc.
Pickuptranscripts,confirmationofenrolmentletters,RESPforms,etc.
Other(specify):___________________________________
CONDITIONS
1. IunderstandthattheAuthorizedRepresentativeispermittedtorepresentmeuptoandincludingtheenddateIhave
selected.
2. IunderstandthatLangaraCollegecollects,usesanddisclosesmypersonalinformationincompliancewiththeprovisionsof
theBritishColumbiaFreedomofInformationandProtectionofPrivacyAct[RSBC1
996,Chapter152]andwillusethe
informationforresearchandstatisticalpurposessubjecttotheprovisionsoftheAct.
3. IunderstandthatifIwishtoextendtheauthorizationperiodIhaveselectedabove,itismyresponsibilitytosubmitanew
ConsentforAuthorizedRepresentativeform.
4. Iun
derstandthatanyrequesttocancelthisauthorizationbeforetheenddateIhaveselectedabovemustbesubmittedin
writing.
5. IunderstandthatifIhavealreadysubmittedaConsentforAuthorizedRepresentativeform,thisformoverridestheprevious
one.
6. Ihavereadandunderstoodth
eabovestatements.
STUDENT’SSIGNATURE:_______________________________________________________DATE:_____________________
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SUBMITCOMPLETEDFORM
Inpersonto:Registrar&EnrolmentServices,LangaraCollege,100West49
th
Ave.,Vancouver,BCV5Y2Z6
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